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Key messages
• Assessvascularriskforalleligiblepeopleaged40-74years.
• Prioritisetheassessmentofpeoplewith10yrCVDrisk≥20%.
• Assessriskofdevelopingdiabetes.
• ProvidehealthylifestyleadviceforallpeopleattendingtheNHSHealthChecktoimproveandmaintainahealthydietandphysicalactivity.Referthoserequiringsupport.
• Advisesmokerstoquitandattendcessationsupportservices.
• Manage≥20%CVDriskandco-morbidities,includinghighdiabetesrisk.
• Checkpulseregularityage≥65years
• Increaseawarenessofdementiainpeopleage≥65years
• RemembertorecordinvitesforNHSHealthChecks.
SUMMARY GUIDELINES
ISBN 978-1-910195-15-4
NHS Health Check
Aim of the guideline
TheaimistoimproveattendanceatNHSHealthChecksandmanageCVDanddiabetesrisktoreduceheartattacks,strokes,chronickidneydiseaseanddiabetesandimprovequalityoflife.
MARCH 2016
Contents
Introduction and background 4
Eligible population and QRisk 5
Invitations, blood tests & assessment 6
Advice and risk communication 7
Managing abnormal risk factors 8
Alcohol units and diabetes diagnosis 9
Dietary advice and physical activity 10
Explaining risk 11
References 11
About the guidance
ThisisaguidetobestpracticeanddoesnotoverridedeliveryrequirementssetoutinlocalservicespecificationsineachCCGwhichmaydifferslightly.ForexamplepulseregularitychecksarenotdoneinallCCGsandtheCVDriskthresholdfortestingcholesterolmaydiffer.
ThisdocumentwasauthoredbyJohnRobsonwiththehelpofMikeFitchett,LuiseDawson,MichaelJones,JayneTaylor,SimonReidandHilaryGuite.
AnyqueriesregardingthisdocumentshouldbeaddressedtoCEGatihse-ceg-admin@qmul.ac.uk58TurnerStLondonE12ABTel:02078822553
NHS HEALTH CHECK SUMMARY GUIDELINE P 3
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Car
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Ris
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NH
S H
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HS
He
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P 4 NHS HEALTH CHECK SUMMARY GUIDELINE
1. Introduction
TheNHSHealthCheckprogrammeisamandatorypublichealthservicewhichisoverseenbytheLocalAuthority.Itisanationalvascularriskassessmentandmanagementprogrammeforpeopleaged40-74years,toreducecardiovasculardisease(CVD).Itdoesnotincludepeoplewithpre-existingCVD,diabetesorthosealreadyonstatins.
TheaimoftheNHSHealthCheckistoimprovehealthoutcomesandthequalityoflifeamongstlocalresidents.ItidentifiespeopleatanearlystageofvascularchangeandprovidesopportunitiestohelpthemreducetheirfutureriskofCVDandprematuremortality.
TheNHSHealthCheckisafacetofaceconsultationwhichisofferedevery5yearstothosewhoareeligible.Inadditiontoreferralformedicalmanagementofidentifiedrisksandco-morbidities,theNHSCheckincludesadviceonlifestyle,referraltolocallifestyleinterventionsandinpeopleover65years,informationtopromotedementiaawareness.
ThislocalguidanceshouldbeconsideredtogetherwiththenationalguidanceonNHSHealthCheckswhichisavailableathttp://www.nhshealthcheck.nhs.uk/Servicespecificationsmaydifferbetweenlocalitiesandthisguidancemayneedtobeadaptedtolocalpolicies.
BACKGROUND
ThisguidanceusesprimarycareasthemainsettingtodelivertheNHSHealthCheckprogramme.Otherapproaches-socialmarketing,pharmacies,occupationalorcommunityinitiatives-maybecomplementary.
It is recommended to prioritise people aged 40–74 years who are at highest CVD risk (20% or more CVD risk). However,this doesnotprecludeopportunisticassessmentanditisexpectedthatoverthe5yearlycyclealleligiblepeopleatallrisks,willbeinvitedtoparticipate.
NICEguidance2014recommendsriskassessmentusingQRisk2.Thiscanbeusedforages30-84yearsbutisrelevanttothe40-74yearagegroupfortheNHSHealthCheck.
NICEalsorecommendsstatintreatmentinpeoplewith10yearCVDriskof10%ormoreasstatinsreduceCVDeventsatthislevelofrisk.(Infactthereisgoodevidenceofbenefitevenlowerat5-7.5%10yearCVDrisk(AmericanACC/AHAGuidance2013).
About8%ofthepopulationisat20%ormoreCVDriskand30%ofthepopulationisat10%ormoreCVDrisk.It is doubtful that given current resources, primary care can systematically deal with everyone at 10% or more risk and a more feasible strategy is to maintain the current treatment priority at 20% but include those at 10% or more risk who have obvious major additional risks including
• extreme obesity BMI 40 or more
• positive FH of MI in 1st degree relatives under 60 yrs
• pre-diabetes
Decisionstorecommendstatinsinthisgroupatintermediateriskshouldbemadeonanindividualbasis.Patientswhodowishtotakestatinsata10%thresholdshouldbesupportedtodoso.SomeCCGsareactivelysupportingannualreviewforthisgroupofpatientswhohavea10-19%CVDrisk.
Treatment at high CVD risk
CVDrisk20%ormore:lifestyleadviceandrecommendatorvastatin20mg(andanti-hypertensiveswhereappropriate).
CVDrisk10%ormore:BMI>40,positiveFHorpre-diabetes:treatasabove
CVDrisk10%ormorewithoutothermajorriskfactors:supportpatientpreferenceforabovetreatment
Atorvastatin20mgisrecommendedfornewpatientsathighCVDrisk.Peoplealreadyonsimvastatin40mgcanremainonthisifpreferred.
See CEG guidance on statins on website (end of document).
NHS HEALTH CHECK SUMMARY GUIDELINE P 5
Co-morbidity
Obesity,raisedbloodpressure,renaldisease,diabetes,pre-diabetesandfamilialhypercholesterolaemiawillalsobeidentifiedbyvascularassessmentrequiringappropriatemanagement.GuidanceforthetreatmentoftheseconditionsisavailablefromNICE(Seebibliographyattheendofthisdocument).
AlcoholisanimportantriskfactorforcardiovasculardiseaseandiscoveredintheAlcoholLocalServicecontracts.
Casefindingforatrialfibrillationusingpulseregularitychecksinpeople65yearsandoverisbeingincludedinlocalCCGs.
Older ages - 75 years or more
AlthoughoutsidetheagerangefortheNHSHealthCheck,almosteveryoneaged75yearsisathighrisk,wihaCVDriskof20%ormore.Thosepeoplenotalreadyonstatinsshouldberecommendedtostartthem.
NICErecommendsconsiderationofstatintreatmentinolderpeople.Allpeopleage75yearsormoreshouldbeconsideredfortreatmentwithatorvastatin20mg(exceptthosewithcontraindications).Treatingtheseolderpeoplewouldhaveconsiderablymoreimpactthatextendingtheagerangetoyoungerpeopleunder40years.Recommendingtreatmentwithstatinsensuresthatolderpeoplealsohaveaccesstothiseffectivemedicaltreatmentandavoidsdiscrimination.
Dementia
Dementiaawarenessisincludedforpeopleaged65yearsorover.Thisshouldincludesignpostingtothememoryclinicifappropriate.
NHS Health Check eligible population
PeoplewiththefollowingconditionsareexcludedfromtheNHSHealthCheckprogrammebecausetheyarealreadymanagedaspartofrecognisedtreatmentprogrammes.
PeoplewithIHD,CKD,TIA/stroke,PAD,familialhypercholesterolaemia,diabetes,heartfailure,atrialfibrillation,hypertension.
Peoplealreadyonstatins,
Peopleat20%ormoreonthehighCVDriskregister.
PeoplewhohavealreadyhadanNHSCheckwithin5years.
QRisk assessment
TheQRISK2assessmentisrecommendedbecause:
Itisanaccurateandequitablemethodtoidentifypeoplewhowillbenefitfromtreatment.
Wherevaluesaremissing,QRISK2usesestimatednumericalvaluesbasedonage-specificpopulationaveragesforcholesterol,weightandbloodpressure,
Peopleestimatedtobeat≥20%riskorpeoplewhohavenodataatall,shouldbeprioritisedforanNHSCheck.
Alleligiblepeopleshouldbeinvitedduringthe5yearcycle.
QRISK website: http://www.qrisk.org/
NHS Health Check training
TheNHShealthCheckisusuallycarriedoutbytrainedHealthCareAssistantsorhealthprofessionalsbasedingeneralpracticebutmaybecarriedoutbytrainedstaffinothersettings.
P 6 NHS HEALTH CHECK SUMMARY GUIDELINE
Invitations: high risk priority
Prioritisingriskisamoreefficientwayofgettingthemosthighriskpeopleassessed.
Theeasiestwaytodothisistoinviteoldestpeoplefirstandthenworkdownthelisttoyoungerages.AlternativelythehighestriskpatientscanbecalledfirstusingQRisk,againworkingdownthelisttolowest.Todothis........
• UsetheEMISbatchprocessortoestimateCVDQRiskineveryoneage40-74years.
• Rankpeopleandinvitehighestriskfirstie.≥20%risk
• Runbatchprocessorannuallytokeepituptodate.
Other priority groups may include
• PatientswithQDiabetesscore>20%.
• PatientswithaSeriousMentalIllness(SMI)orLearningDisability
• Peoplewithoutrecordsofbloodpresure
Recording Invitations
Usearangeofmethodstocontactindividuals(phone/letter/email/opportunistic)
The invitation MUST be recorded on the NHS Health Check template.
PublicHealthEnglandusesrecordofinvitationforitsuptakefiguresonwhichtheLocalAuthorityisassessed.
NHS Health Check
Explanation:
• ReasonsfortheNHSHealthCheckassessment,itsbenefitsandconsequences
• Causesofandopportunitiestopreventheartattacks,strokesanddiabetes
OpportunitiesforHealthyLifestylesupport
• WillusuallytaketwovisitsinpeoplewithCVDriskgreaterthan10%,becausetheyrequireabloodtest.
Blood tests
• FASTINGbloodsampleareNOTgenerallyrequired.
NICEGuidance2014statesthatafastingsampleisNOTrequiredforcholesterol,HDLcholesterolandHbA1cdoesnotrequirefasting.
• FullliverfunctiontestsLFTsareNOTrequired
AsingleALTtestisallthatisnecessaryifassessingbeforestatintreatmentandnotagainunlessclinicallyindicated.
Inpatientsknowntohaveliverdiseaseorwhoareknowntobeathighrisk(eg.alcoholexcess,HepatitisBorC),fullLFTsarenecessary.InthesepeopleNICEadvisestestingbeforestartingstatins,within6monthsandat12monthsandnotagainunlessclinicallyindicated.
• Peopleunder10%CVDriskwithnootherriskfactorsdonotneedabloodtestandasinglevisitwillusuallysuffice
Assessing CVD and diabetes risk
Assessment• Age,Gender,Ethnicity
• Smokingstatus
• Familyhistoryofischaemicheartdiseaseinafirstdegreerelative(mother/father/brotherorsister)under60years.Thisshouldberecordedifeither negative or positive
• BodyMassIndex
• BloodpressuremeasurementIf≥140/90mmHgrepeat3timesanduselastvalue
• Alcoholscreening(AUDIT-C)
• Physicalactivityassessment:inactive,moderatelyinactive,moderatelyactiveoractive(GPPAQ)
• Age≥65years.Pulsecheck-regularorirregular
• Age≥65years.Informaboutdementia
• Cancerscreeningadvice(breast,bowelandcervical)
• RandomtotalcholesterolandHDLcholesterolbloodtest(onlyusefulinpeopleover10%CVDrisk,positiveFHorhyperglycaemicstates.Inpeopleunder5%CVDriskcholesteroltestingconfersnoadvantageasitdoesnotinfluencemanagement). Note that PHE advises testing in everyone.
Otherbloodtestswilldependonrisksfound-seepage8.
NHS HEALTH CHECK SUMMARY GUIDELINE P 7
Follow-up of CVD risk
• ThosewhoarebelowQRisk10%shouldbeinformedthattheirnextNHSHealthCheckwillbeduein5yearstime.
• ThosewithCVDrisk20%ormoreorthosewithabnormalriskfactorsorco-morbiditiesshouldmakeanappointmenttoseeaGPorPNforfurthermanagement.
• Practicesshouldmakearrangementstoannuallyreviewpeopleat10%-19%CVDriskinLocalAuthoritieswhichsupportthisreview.
Lifestyle advice
ThepracticewillprovidehealthylifestyleadvicetoALLpatientsafteranNHSHealthCheckonhowtomaintain/improvetheirvascularhealthanddirectpatientstolocalserviceswhichsupportthis.
Thepracticewillprovideatailoredpackageofinterventionsandreferralwhereapproriateforpatientswithidentifiedriskfactorsincludingarrangmentsforannualfollow-up.
• CVDriskscore≥20%(codeashighCVDriskontemplate)
• highriskofdiabetes
The practice should record on the template if the offer of a statin is declined or contraindicated.
• smoker• physicalinactivity• BMI≥30or27.5inSouthAsians.• AlcoholAuditCscore≥8
adviceandreferralontotheappropriatelocalserviceorcarepathway
LocalAuthorityservicesforhealthyeating,weightmanagementandphysicalactivityinclude
• Smokingcessationservice• Alcoholsupportservices• Localadviceservices–(LAwebsite)• Pre-diabetesservices
Communication of risk
StaffdeliveringtheNHSHealthCheckshouldbetrainedincommunicating,capturingandrecordingtheriskscoreandresults,andunderstandthevariablesusedbytheriskenginetocalculatetheriskscore.
Ageisthemainfactordeterminingrisk.Menareathigherriskthanwomen.Ofthefactorswecandosomethingabout,smokingisthemostimportantanddoublesrisk.Hypertensionisthenextmostimportantriskfactor.
Inpeoplewithapositivefamilyhistoryinafirstdegreerelativeunderage60yearsthisequivalenttotheriskofsmoking.Peoplewithpositivefamilyhistoriesshouldbeinvestigatedandmanymoreshouldbetreatedwithstatins.
BeingphysicallyactiveprotectspeopleagainstCVD-evenwalkingamoderateamounthelps.
TheresultsoftheNHSHealthCheckshouldbeexplainedtoeachpatient.Thisshouldbeface-to-faceandtailoredtoeachindividualtomaximisepatientunderstanding.
Comminicating risk, staff should:
• communicateriskineveryday,jargon-freelanguagesothatindividualsunderstandtheirlevelofriskandwhatchangestheycanmaketoreducetheirrisk
• usebehaviourchangetechniques(suchasmotivationalinterviewing)todeliverappropriatelifestyleadviceandhowitcanreducetheirrisk
• createatwo-waydialoguetoexploreindividualvaluesandbeliefstofacilitateaclient-centredrisk-reductionplan
• givepeopleadequatetimetoaskquestionsandobtainfurtherinformationabouttheirriskandresults
• CommissionersandprovidersshouldconsiderdevelopmentofappropriatewritteninformationforattendeestotakeawaywiththemfromtheNHSHealthCheck
• Thiswritteninformationshouldincludepersonalisedfeedbackexplainingthat...
• Forsmokers,stoppingsmokingisthesinglemostimportantwaytoreduceCVDrisk
• Informationontheirpersonalrisksandwhatthesemean:CVDriskscore,BMI,cholesterollevel,bloodpressure,AUDITCandanyreferralsontolifestyleorclinicalservices
• Theimportanceofchangesindietandphysicalactivityandavailablesupportservices
P 8 NHS HEALTH CHECK SUMMARY GUIDELINE
Abnormal risk factors
Peoplefoundtohavetheabnormalriskfactorslistedbelowwillusuallyrequiretwovisits.ThisisbecauseserumtotalandHDLcholesterolresultswilloftennotbeavailableuntilthesecondvisitandalsobecausethetimeavailableinasinglevisitisnotalwayssufficienttoallowafullexplanationofidentifiedriskfactorsandnecessaryadvice,actionsandreferrals.
Additional blood tests include
Ifbloodpressure≥140/90mmHg(3readings)orifCVDrisk≥20%,
Bloods required:HbA1c,ALT, eGFR and referral to GP.
IfQDscore≥20%orifObesityBMI≥30(27.5SouthAsian)HbA1c
IfPositiveFHprematureIHDFasting lipid profile
Smoking Stopsmokingadviceandreferraltolocalstopsmokingservice.
Obesity BMI ≥30; 27.5 South Asians
Adviseondietandphysicalactivity.Offerreferraltosupportservices.Seelastpageofguidelineforbasicdietaryadvice.
CVD Risk 20% or more
Addpatienttothehighriskregisterforannualfollowupandexitfromtheprogramme.
Offeratorvastatin20mg(recordifofferdeclined)andlifestyleadvice.
CVD Risk 10-19%RecommendtreatmentasaboveifBMI>40,positiveFH,orpre-diabetes.Ifnomajorriskfactorssupporttreatmentbypatientchoice.Annualfollow-upifsupportedbyCCG.
Hypertension assessment CheckbloodpressureaccordingtoNICEguidanceandlocalpathways.
Chronic Kidney Disease (CKD)
WhereeGFRisbelow60ml/min/1.73m2,managementandassessmentforchronickidneydiseaseisrequiredinlinewiththeNICEguidelineandlocalpathways.
Alcohol risk assessmentAfullAUDITassessmentisindicatedbyanAUDITCscore≥5
IftheindividualmeetsorexceedstheAUDITthresholdof8briefadviceshouldbegiven.Referraltolocalalcoholservicesshouldbeconsideredforindividualsscoring20ormore.(seeNICEpublichealthguideline2010forfurtherdetails)
Familial hypercholesterolemia
PatientswhohaveBOTHatotalcholesterol>7.5mmol/LANDapositiveFHofIHDinafirstdegreerelativeunderage60years,shouldbeassessedforfamilialhypercholesterolemiawithfullfastinglipidprofile,HbA1candthyroidfunctiontest.Ifthesetestsarenotinformative,orinthosewithacholesterolof>9mmol/Lconsiderspecialistreferral.
Type 2 diabetes risk assessment
TheNHSCheckwillalsoestimatetheriskofdevelopingdiabetes(QDiabetes).
CheckHbA1ctodetectpre-diabetesordiabetesforpatientswiththefollowingcriteria:
• QDiabetes20%ormoreorQRisk20%ormore
• BMI≥30(or≥27.5totriggeractioninIndian,Pakistani,Bangladeshi,otherAsianorChinese).
• Abloodpressuresustainedabove140mmHgsystolicor90diastolicmmHg.
ThesepatientsshouldreceiveanHbA1ctestwhichcanbeusedforcasefindingofdiabetesorpre-diabetes.InafewpeopleitmaybenecessarytouseFastingGlucose.
ThereisnonationalconsensusontestingandproceduresdifferinCCGsforpeoplefoundtohaveabnormalHbA1c.SomeCCGsconfirmwithfurtherfastingbloodglucosetests.
See CEG Website: Diagnosing Diabetes CEG 2013:http://www.blizard.qmul.ac.uk/ceg-resource-library/clinical-guidance.html
NHS HEALTH CHECK SUMMARY GUIDELINE P 9
New co-morbidity
Newlydiagnosedpatientswithdiabetes,hypertension,chronickidneydiseaseorpatientsathigh-riskofaCVDeventwillbeplacedontherespectiveregister.ThesepatientswillexittheNHSCheckprogramme
FurtherreferenceshouldbemadetoNHSHealthCheckBestPracticeGuidance2015foundonthefollowingsitehttp://www.healthcheck.nhs.uk.
Alcohol Units
This is one unit of alcohol…
…andeachoftheseismorethanoneunit
P 10 NHS HEALTH CHECK SUMMARY GUIDELINE
Dietary advice
1. FATSReducetotalfatandsaturatedinthediet-removevisiblewhitefatinmeatandchickenskin.Avoidprocessedmeatssuchassausage,kebabs,mincemeatsandburgerswhichareVERYhighinfats.Avoidtakeawayfastfoodslikefriedchicken,curry,chips,chineseandkebabmealsthatareveryhighinfat.
Useskimmedmilkandlowfatnaturalyoghurt.
Avoidcheese,butterorgheewhicharesolidfat.
Usesunflower,rapeseed,cornoroliveoilspreadsinsteadwhichcontainpolyunsaturatedormonounsaturatedfats.Note:thesespreadsandoilsareashighincaloriesassaturatedfats,butnotsobadfortheheart-soforpeoplewishingtoloseweight,onehastoreduceallfatintakeincludingthese.
Avoid‘vegetableoil’whichdoesn’tsaywhatitis-itoftencontainscoconutoilorpalmoilthataresaturatedfats,notgoodfortheheart.
2. SUGARSAvoidsweetdrinksincludingfruitjuiceevenif‘freshlysqueezed’.Alargeglassoffreshsqueezedorangejuicecontainsalmostasmanycalories,(106kcal)ashalfabarofchocolate(115kcal).Aregularcanofcokeorlemonadeis(140kcal).ChocolatebarslikeMarsbars,CadburysorKitKatsaretypicallyabout(240kcal).
Drinkwaterorlowcaloriedrinks.
Fruitjuiceorsweetdrinksofanykindarea‘treat’likesweets.Sweetdrinksandfruitjuicearenotanessentialpartofamealandarenotgoodforchildrenasitalsorotstheirteethifdrunkregularlyandcausesobesity.Smoothiesarealsooftenhighinsugarandcalories.
Foodswithaddedsugarsincludingsweetenedbreakfastcerealsorgranolatypemixesoftenhavealmostasmanycaloriesassweets.Biscuitsandcakesarealsoveryhighinbothfatandsugar.
3. ALCOHOL Excessalcoholisharmfultotheliverandtotheheart.Itisamajorsourceofcaloriesandacauseofobesity.Thereareasmanycaloriesinalargeglassofwine(230kcal)asinachocolatebarandapintofbeeris(180kcal)whichis3/4ofachocolatebar.
4. BETTER FOODS• Eatmoregreenvegetablesandsalads
• Eatfreshfruit-atleast2portionsaday.• Eatmorepulseslikelentils,dhalandbeans• Eatmorefishespeciallyoilyfishlikeherring,mackerel,sardinesandsalmon.
Physical activity
Physicalactivityisveryimportanttoprotectagainstheartdiseaseandstroke.Itisaveryunderratedfactorbutevensmallchangesinphysicalactivityhaveabigeffectonreducingtherisk.Walkingatleasthalfanhouradayisaminimum.Themoreactivityyoudothebetteritisforyourarteries,heartandbrain.Walkingpartofthewaytowork,totheshops,upthestairsordoingmorevigorousactivityateveryopportunityisbeneficialtoyourheart.
NHS HEALTH CHECK SUMMARY GUIDELINE P 11
20% 1 in 5
10%1 in 10
5% 1 in 20
References• LipidmodificationandCVDrisk http://www.nice.org.uk/guidance/cg181
• Type2diabetes https://www.nice.org.uk/guidance/ng28
• Obesity http://www.nice.org.uk/guidance/cg189
• Hypercholesterolaemia https://www.nice.org.uk/guidance/cg71
• Hypertension http://www.nice.org.uk/guidance/cg127
• CKDguidance http://www.nice.org.uk/guidance/cg182
• Bloodpressuremeasurement http://www.nice.org.uk/guidance/cg127
• DiagnosingDiabetesCEG. http://www.blizard.qmul.ac.uk/ceg-home.html
• StatinguidanceCEGhttp://www.blizard.qmul.ac.uk/ceg-resource-library/clinical-guidance.html
• NHSHealthChecksPHEhttp://www.nhshealthcheck.nhs.uk/
Explaining QRisk and QDiabetes risk.
A high risk is a 20% risk: a 1 in 5 chance of having the condition in 10 years.
A moderately high risk is a 10% risk: a 1 in 10 chance of having the condition in 10 years
A lower risk is less than 5%: less than 1 in 20 chance of having the condition in 10 years.
Risk of death from a motor vehicle accident is 1 in 3000 and for a cyclist 1 in 40,000 in 10 years
Centre for Primary Care and Public HealthBarts and The London School of Medicine and DentistryYvonne Carter Building58 Turner StreetLondon E1 2ABTel: 020 7882 2553 Fax: 020 7882 2522email: ihse-ceg-admin@qmul.ac.ukwebsite: http://www.blizard.qmul.ac.uk/ceg-home.html
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