Increased Ion Temperature and Neutron Yield Observed in Magnetized Indirectly Driven D_{2}-Filled Capsule Implosions on the National Ignition Facility

The application of an external 26 Tesla axial magnetic field to a D_{2} gas-filled capsule indirectly driven on the National Ignition Facility is observed to increase the ion temperature by 40% and the neutron yield by a factor of 3.2 in a hot spot with areal density and temperature approaching what is required for fusion ignition [1]. The improvements are determined from energy spectral measurements of the 2.45 MeV neutrons from the D(d,n)^{3}He reaction, and the compressed central core B field is estimated to be ∼4.9  kT using the 14.1 MeV secondary neutrons from the D(T,n)^{4}He reactions. The experiments use a 30 kV pulsed-power system to deliver a ∼3  μs current pulse to a solenoidal coil wrapped around a novel high-electrical-resistivity AuTa_{4} hohlraum. Radiation magnetohydrodynamic simulations are consistent with the experiment.

176 EXPLORING THE PREVALENCE AND PRESENTATION OF FRAILTY IN AN IRISH EMERGENCY DEPARTMENT – A POINT PREVALENCE STUDY

Background

In Ireland, frailty is routinely identified in the Emergency Department (ED), however its prevalence is not well defined. This contrasts with the prevalence of frailty in the older adult population living in the community setting, where the prevalence of frailty has been defined as 14% in the over 65 population and 33% in the 75 and over (TILDA, 2020). The aim of the study is to explore the prevalence and presentation of frailty in the older adult population attending ED of a model 3 hospital in Ireland.

Methods

In August 2021, a point prevalence study was undertaken in the ED over 14 days, covering a 24-hour period, applying retrospective documentary and observational data analysis. Measures used to identify frailty included: Think Frailty and Clinical Frailty Scale (CFS) version 2.0.

Results

2,582 individuals attended ED over a 2-week period. 22% were aged 65 and over, of which, 37.5% were aged 65 – 74 and 62.5% were aged 75 and over. 60% were admitted and 40% were discharged. Of those identified as living with frailty – 24.8% were identified to be living with severe/very severe frailty (CFS 7 – 8); 19.5% with moderate frailty (CFS 6), and 35.66% with mild/very mild frailty (CFS 4 – 5). The majority of those identified at CFS 1 – 3 were aged 65 – 74. The identified frailty syndromes included, polypharmacy (38.5%), reduced mobility (30.3%), falls (20%), dementia (6%), Delirium (5%), Incontinence (0%).

Conclusion

The results indicated that 80% of the identified cohort were living with frailty (CFS 4 – 8). Frailty status and advancing age were associated with a longer length of stay in ED and a subsequent admission. Dominant frailty syndromes included polypharmacy and reduced mobility; frailty syndromes such as delirium and incontinence appear to be underrepresented, which may be influenced by the absence of routine identification in the ED.

98 PREPARING FOR THE COMMENCEMENT OF THE DECISION MAKING “CAPACITY” ACT (2015): REVIEWING CURRENT PRACTICE WITHIN AN OCCUPATIONAL THERAPY DEPARTMENT

Background

The Decision Making ‘Capacity’ Act (2015) will commence in 2022. This will have significant implications for health care professionals. Occupational therapists undertake a wide range of assessments of cognitive, physical and functional ability. There is a need to streamline the recording of comprehensive and holistic assessment outcomes for easier access and interpretation during the interdisciplinary assessment of Decision Making Capacity (DMC) for independent living. A working group was established to review current practices and formulate a document to support the assessment.

Methods

The model for improvement was employed, which incorporates the plan, do, study, act methodology. Current practice of the occupational therapy team was reviewed in relation to assessments used, the format of recording and the knowledge of the DMC act. A working document was formulated and reviewed with medical staff. Team education on the DMC act was provided. A qualitative questionnaire was circulated among the occupational therapy staff to ascertain the educational needs of the department. Perceptions of current practice in DMC assessment of independent living were gathered.

Results

100% of questionnaire respondents identified need for further training and education on the DMC Act 2015. No respondents agreed that the relevant assessment outcomes were easily accessible. 67% of respondents were unsatisfied with the current process in place for DMC assessment of independent living. 45% of respondents do not feel confident in completing assessments contributing to DMC assessment of independent living. There was no consistency in the format of recording assessment outcomes.

Conclusion

The group developed a clinical document to improve easy and consistent interpretation of occupational therapy assessment in relation the DMC assessment of independent living. This ensures person centred, comprehensive assessment to enhance the patient journey. The team are better prepared for the commencement of the DMC act and have identified future training needs.

“Uroptysis!” – A case report of xanthogranulomatous pyelonephritis with nephrobronchial fistulation

Introduction and importance

Xanthogranulomatous pyelonephritis (XGP) is an uncommon complication of chronic urinary tract infection, classically secondary to a chronic obstructive uropathy, resulting in destruction of renal parenchyma and a non-functioning kidney (Jha and Aeddula, 2022 [1]). This is rarely associated with nephrobronchial fistulation, with few published case reports in the literature to date.

Case presentation

We present the rare case of a 42-year-old female who was admitted to an Irish tertiary urology centre with abdominal pain, elevated inflammatory markers and an obstructive uropathy on initial imaging, with a new diagnosis of XGP. Initial management was with targeted intravenous antimicrobial therapy, percutaneous nephrostomy and perinephric drain insertion. The subsequent discovery of a nephrobronchial fistula later complicated the case, warranting plan for interval nephrectomy and fistula repair following prolonged medical management. We discuss the initial presentation, workup and image-guided approach to management.

Clinical discussion

XGP is an uncommon sequela of chronic renal suppurative infection, and is usually associated with long-standing ureteric obstruction secondary to a staghorn calculus. Nephrobronchial fistulation is a rare complication of XGP, highlighting the significance of this case discussion.

Conclusion

XGP should be considered in cases of suspected chronic pyelonephritis and may rarely lead to nephrobronchial fistulation. In cases of known XGP and pleural empyema, nephrobronchial fistulation should be considered as part of the differential diagnosis.

•

Xanthogranulomatous pyelonephritis is rare and associated with chronic upper urinary tract infection and obstruction.

•

Nephrobronchial fistulation is a rare complication of xanthogranulomatous pyelonephritis.

•

In cases of XGP and concurrent pleural empyema, a nephrobronchial fistula should be considered.

Extended length of stay and related costs associated with dementia in acute care hospitals in Ireland

OBJECTIVE

To estimate the additional impact of dementia on in-patient length of stay (LOS) and related costs in Irish acute hospitals. Both principal and secondary diagnosis effects are estimated and valued.

METHODS

This is a cross-sectional study based on administrative data collected on all public hospital in-patient discharges in Ireland for people aged 65 years and older in 2019. Coarsened exact matching (CEM) was undertaken to account for observed confounders between dementia and non-dementia groups, while generalised linear modelling (GLM) was used to compare differences in LOS.

RESULTS

Patients with a principal diagnosis of dementia spent on average 17.5 (CI: 15.42, 19.56; p < .01) d longer in hospital than similar patients with no principal diagnosis of dementia. LOS was 6.7 (CI: 6.31, 7.14; p < .01) d longer for patients with a secondary diagnosis of dementia compared to similar patients with no secondary diagnosis of dementia. The additional annual cost of care for patients in hospitals with a secondary (principal) diagnosis of dementia was €62.0 million (€13.2 million).

CONCLUSIONS

This study highlights the economic impact of extended LOS for patients with dementia in Irish acute hospitals. Addressing specific dementia-related needs of people in hospital is likely to optimise resource use and decrease health care costs in acute care settings.

Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database

The effectiveness of emergency surgery vs. non-emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non-emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre-specified sub-groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95%CI) for emergency surgery minus non-emergency surgery after adjusting for confounding: -0.73 days (-2.10-0.64) for appendicitis; 0.60 (-0.10-1.30) for gallstone disease; -2.66 (-15.7-10.4) for diverticular disease; -0.07 (-2.40-2.25) for hernia; and 3.32 (-3.13-9.76) for intestinal obstruction. For patients with 'severe frailty', mean differences (95%CI) in days alive and out of hospital for emergency surgery were lower than for non-emergency surgery strategies: -21.0 (-27.4 to -14.6) for appendicitis; -5.72 (-11.3 to -0.2) for gallstone disease, -38.9 (-63.3 to -14.6) for diverticular disease; -19.5 (-26.6 to -12.3) for hernia; and - 34.5 (-46.7 to -22.4) for intestinal obstruction. For patients without frailty, the mean differences (95%CI) in days alive and out of hospital were: -0.18 (-1.56-1.20) for appendicitis; 0.93 (0.48-1.39) for gallstone disease; 5.35 (-2.56-13.28) for diverticular disease; 2.26 (0.37-4.15) for hernia; and 18.2 (14.8-22.47) for intestinal obstruction. Emergency surgery and non-emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non-emergency surgery strategies for these conditions may be modified by patient factors.

Safety of elective paediatric surgery during the coronavirus disease 2019 pandemic

INTRODUCTION

Corona-virus Disease 2019 (COVID-19) has had a huge impact on the delivery of healthcare worldwide, particularly elective surgery. There is a lack of data regarding risk of postoperative COVID-19 infection in children undergoing elective surgery, and regarding the utility of pre-operative COVID-19 testing, and preoperative "cocooning" or restriction of movements. The purpose of this present study was to examine the safety of elective paediatric Otolaryngology surgery during the COVID-19 pandemic with respect to incidence of postoperative symptomatic COVID-19 infection or major respiratory complications.

MATERIALS AND METHODS

Prospective cohort study of paediatric patients undergoing elective Otolaryngology surgery between September and December 2020. Primary outcome measure was incidence of symptomatic COVID-19 or major respiratory complications within the 14 days after surgery. Parents of prospectively enrolled patients were contacted 14 days after surgery and enquiry made regarding development of postoperative symptoms, COVID-19 testing, or diagnosis of COVID-19.

RESULTS

302 patients were recruited. 125 (41.4%) underwent preoperative COVID-19 RT-PCR testing. 66 (21.8%) restricted movements prior to surgery. The peak 14-day COVID-19 incidence during the study was 302.9 cases per 100,000 population. No COVID-19 infections or major respiratory complications were reported in the 14 day follow-up period.

CONCLUSION

The results of our study support the safety of elective paediatric Otolaryngology surgery during the pandemic, in the setting of community incidence not exceeding that observed during the study period.

COVID-19 - Interventions and lifestyle factors that prevent infection or minimise progression to severe disease

Background

This evidence summary synthesised the evidence relating to pharmacological and non-pharmacological interventions in the community to prevent COVID-19/progression to severe disease. An additional aim was to identify potentially modifiable lifestyle factors associated with reduced risk of infection/progression to severe disease.

Methods

A systematic search of published peer-reviewed articles and non-peer-reviewed pre-prints was undertaken from 1 January 2020 to 19 April 2021; no language restrictions were applied. All potentially eligible papers were exported to Covidence. Titles/abstracts and full texts were single screened for relevance. Data extraction and quality appraisal of included studies was completed by a single reviewer and checked by a second.

Results

In total, 50 studies, three randomised controlled trials (RCTs), one non-RCT and 46 cohort studies were included. The four included controlled trials tested variations of the pharmacological intervention, ivermectin. While these controlled trials reported a protective effect for ivermectin use, these trials were of poor quality and had serious risk of bias. Across 46 cohort studies, the modifiable lifestyle risk factors identified were obesity, smoking, vitamin D status, physical activity, alcohol consumption and processed meat consumption. These studies reported mixed results in terms of the association between modifiable lifestyle risk factors and poor COVID-19 outcomes.

Conclusions

At the time of writing there is no high quality evidence of benefit to support pharmacological interventions to prevent COVID-19. Although there were mixed results for the risk factors identified, maintenance of healthy weight, smoking cessation, engaging in physical activity and moderation of alcohol and processed meat consumption are likely to be beneficial to health and should continue to be encouraged.

Admission to long-stay residential care and mortality among people with and without dementia living at home but on the boundary of residential care: a competing risks survival analysis

BACKGROUND

Health policy in many countries is underpinned by a commitment to support dependent older people to remain in their own home for as long as possible and practicable. This study explores factors affecting both admission to long-stay residential care (LSRC) and mortality among people with and without dementia who are currently living at home with intensive formal care support.

METHODS

This is a cross-sectional study based on administrative data collected on 429 dependent older people in Ireland, 269 of whom were people with dementia. A cause-specific hazard model was used to investigate the hazard of admission to LSRC, while accounting for mortality as a competing risk and vice versa.

RESULTS

Admission to LSRC was higher for people with dementia relative to people without and for those receiving lower amounts of informal care. The hazard of mortality was significantly higher for older people aged 85+, whereas it was lower for individuals with a medium level of dependency relative to those with high levels of dependency. The hazard of mortality was also influenced by the amount of informal care provision.

CONCLUSION

People with dementia are more likely to be admitted to LSRC than people without. Care for people with dementia needs to be more specialised and personal, and intensity of provision should not be equated to the number of care hours on offer. Informal care provision may help to prevent admission to LSRC. Advanced age, physical dependency and informal care provision affect mortality, raising interesting issues in relation to resource allocation.

Stress-related health depreciation: Using allostatic load to predict self-rated health

Approximately one quarter of UK adults are currently diagnosed with two or more chronic conditions, often referred to as multimorbidity. Chronic stress has been implicated in the development of many diseases common to multimorbidity. Policymakers and clinicians have acknowledged the need for more preventative approaches to deal with the rise of multimorbidity and "early ageing". However divergence may occur between an individual's self-rated health and objectively measured health that may preclude preventative action. The use of biomarkers which look 'under the skin' provide crucial information on an individual's underlying health to facilitate lifestyle change or healthcare utilisation. The UK's Understanding Society dataset, was used to examine whether baseline variation in biomarkers measuring stress-related "wear and tear" - Allostatic Load (AL) - predict changes in future self-rated health (SRH) while adjusting for baseline SRH, socioeconomic and lifestyle factors, and healthcare inputs. An interaction between baseline AL and baseline SRH was included to test for differential rates of SRH change. We examined SRH using the SF6D instrument, measuring health-related-quality of life (HRQoL), as well as its physical and mental health components separately. We found that HRQoL and physical health decline faster for those with higher baseline AL (indicating greater "wear and tear") however the same pattern was not observed for mental health. These findings provide novel insights for clinicians and policymakers on the usefulness of AL in capturing health trajectories of which individual's may not be aware and its importance in targeting resilience enhancing measures earlier in the lifecourse to delay physical health decline.

Experience of point-of-care HbA1c testing in the English National Health Service Diabetes Prevention Programme: an observational study

INTRODUCTION

To report the observations of point-of-care (POC) glycated hemoglobin (HbA1c) testing in people with non-diabetic hyperglycemia (NDH; HbA1c 42-47 mmol/mol (6.0%-6.4%)), applied in community settings, within the English National Health Service Diabetes Prevention Programme (NHS DPP).

RESEARCH DESIGN AND METHODS

A service evaluation assessing prospectively collected national service-level data from the NHS DPP, using data from the first referral received in June 2016-October 2018. Individuals were referred to the NHS DPP with a laboratory-measured HbA1c in the NDH range and had a repeat HbA1c measured at first attendance of the program using one of three POC devices: DCA Vantage, Afinion or A1C Now+. Differences between the referral and POC HbA1c and the SD of the POC HbA1c were calculated. The factors associated with the difference in HbA1c and the association between POC HbA1c result and subsequent attendance of the NHS DPP were also evaluated.

RESULTS

Data from 73 703 participants demonstrated a significant mean difference between the referral and POC HbA1c of -2.48 mmol/mol (-0.23%) (t=157, p<0.001) with significant differences in the mean difference between devices (F(2, 73 700)=738, p<0.001). The SD of POC HbA1c was 4.46 mmol/mol (0.41%) with significant differences in SDs between devices (F(2, 73 700)=1542, p<0.001). Participants who were older, from more deprived areas and from Asian, black and mixed ethnic groups were associated with smaller HbA1c differences. Normoglycemic POC HbA1c versus NDH POC HbA1c values were associated with lower subsequent attendance at behavioral interventions (58% vs 67%, p<0.001).

CONCLUSION

POC HbA1c testing in community settings was associated with significantly lower HbA1c values when compared with laboratory-measured referrals. Acknowledging effects of regression to the mean, we found that these differences were also associated with POC method, location, individual patient factors and time between measurements. Compared with POC HbA1c values in the NDH range, normoglycemic POC HbA1c values were associated with lower subsequent intervention attendance.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Variables associated with survival in patients with invasive bladder cancer with and without surgery

We recorded the survival of 141 patients assessed for radical cystectomy, which included cardiopulmonary exercise testing. The median Kaplan-Meier survival estimates were: 1540 days for the whole cohort; 2200 days after cystectomy scheduled (n = 108); and 843 days without surgery. The mortality hazard remained double that expected for a matched general population, but survival was better in patients scheduled for surgery than those who were not: the mortality hazard ratio (95%CI) after cystectomy was 0.43 (0.26-0.73) the mortality hazard without surgery, p = 0.001. The mortality hazard ratios for the three-variable Bayesian Model Averaging survival model for all 141 patients were: referral for surgery (0.5); haemoglobin concentration (0.98); and efficiency of carbon dioxide output (1.05). Efficiency of carbon dioxide output was the single variable in the postoperative model (n = 108), mortality hazard 1.08 (per unit increase). The ratio of observed to expected peak oxygen consumption associated best with mortality in 33 patients not referred for surgery, hazard ratio 0.001. Our results can inform consultations with patients with invasive bladder cancer and suggest that interventions to increase fitness and haemoglobin may improve survival in patients who do and who do not undergo radical cystectomy.

Diabetes in the UK: 2019

AIM

Diabetes impairs the quality of life of people living with the condition and is a major public health concern. The aim of this paper is to create a state of the nation report of diabetes in the UK.

METHODS

Diabetes UK collates information about diabetes from diverse sources. This paper synthesizes these data to create a national report.

RESULTS

Some 7% of the UK population are now living with diabetes; approximately one million people have undiagnosed type 2 diabetes, 40 000 children have diabetes and more than 3000 children are diagnosed every year. Forty-nine per cent of people with type 1 diabetes were offered structured education, but only 7.6% attended; the corresponding figures for type 2 diabetes were 90% and 10.4%, respectively. Among people with diabetes, 28% reported having issues obtaining medication or equipment for self-management. Fifty-seven per cent of people with type 1 diabetes and 42% with type 2 diabetes do not receive all eight annual health checks. Around 40% of people with diabetes have diminished psychological well-being. One-third of people have a microvascular complication at the time of diagnosis of type 2 diabetes. Diabetes is responsible for 530 myocardial infarctions and 175 amputations every week. The National Health Service spends at least £10 billion a year on diabetes, equivalent to 10% of its budget; 80% is spent treating complications. One in six hospital inpatients has diabetes.

CONCLUSION

Diabetes continues to place a significant burden on the individual with diabetes and wider UK society. This report will be updated annually to understand how diabetes is changing across the UK.

Early Outcomes From the English National Health Service Diabetes Prevention Programme

OBJECTIVE

To assess weight and HbA_1c changes in the Healthier You: National Health Service Diabetes Prevention Programme (NHS DPP), the largest DPP globally to achieve universal population coverage.

RESEARCH DESIGN AND METHODS

A service evaluation assessed intervention effectiveness for adults with nondiabetic hyperglycemia (HbA_1c 42-47 mmol/mol [6.0-6.4%] or fasting plasma glucose 5.5-6.9 mmol/L) between program launch in June 2016 and December 2018, using prospectively collected, national service-level data in England.

RESULTS

By December 2018, 324,699 people had been referred, 152,294 had attended the initial assessment, and 96,442 had attended at least 1 of 13 group-based intervention sessions. Allowing sufficient time to elapse, 53% attended an initial assessment, 36% attended at least one group-based session, and 19% completed the intervention (attended >60% of sessions). Of the 32,665 who attended at least one intervention session and had sufficient time to finish, 17,252 (53%) completed: intention-to-treat analyses demonstrated a mean weight loss of 2.3 kg (95% CI 2.2, 2.3) and an HbA_1c reduction of 1.26 mmol/mol (1.20, 1.31) (0.12% [0.11, 0.12]); completer analysis demonstrated a mean weight loss of 3.3 kg (3.2, 3.4) and an HbA_1c reduction of 2.04 mmol/mol (1.96, 2.12) (0.19% [0.18, 0.19]). Younger age, female sex, Asian and black ethnicity, lower socioeconomic status, and normal baseline BMI were associated with less weight loss. Older age, female sex, black ethnicity, lower socioeconomic status, and baseline overweight and obesity were associated with a smaller HbA_1c reduction.

CONCLUSIONS

Reductions in weight and HbA_1c compare favorably with those reported in recent meta-analyses of pragmatic studies and suggest likely future reductions in participant type 2 diabetes incidence.

A phantom study of the performance of model-based iterative reconstruction in low-dose chest and abdominal CT: When are benefits maximized?

INTRODUCTION

The aim of this study was to assess and compare the effects of CT image reconstruction techniques on low-dose CT image quality using phantoms.

METHODS

Anthropomorphic torso and spatial/contrast-resolution phantoms were scanned at decreasing tube currents between 400 and 10 mA. CT thorax and abdomen/pelvis series were reconstructed with filtered back projection (FBP) alone, combined 40% adaptive statistical iterative reconstruction & FBP (ASIR40), and model-based iterative reconstruction (MBIR) [(resolution-preference 05 (RP05) and RP20 in the thorax and RP05 and noise-reduction 05 (NR05) in the abdomen)]. Two readers rated image quality quantitatively and qualitatively.

RESULTS

In thoracic CT, objective image noise on MBIR RP05 data sets outperformed FBP at 200, 100, 50 and 10 mA and outperformed ASIR40 at 50 and 10 mA (p < 0.001). MBIR RP20 outperformed FBP at 50 and 10 mA and outperformed ASIR40 at 10 mA (p < 0.001). Compared with both FBP and ASIR40, MBIR RP05 demonstrated significantly better signal-to-noise ratio (SNR) at 10 mA. In abdomino-pelvic CT, MBIR RP05 and NR05 outperformed FBP and ASIR at all tube current levels for objective image noise. NR05 demonstrated greater SNR at 200, 100, 50 and 10 mA and RP05 demonstrated greater SNR at 50 and 10 mA compared with both FBP and ASIR. MBIR images demonstrated better subjective image quality scores. Spatial resolution, low-contrast detectability and contrast-to-noise ratio (CNR) were comparable between image reconstruction techniques.

CONCLUSION

CTs reconstructed with MBIR have lower image noise and improved image quality compared with FBP and ASIR. These effects increase with reduced radiation exposure confirming optimal use for low-dose CT imaging.

Emergency department and hospital care prior to suicide: A population based case control study

BACKGROUND

High proportions of those who die by suicide in Northern Ireland (NI) are not known to mental health services, making it important to understand contact with the wider health services. Previous research has not examined the patterns of emergency department (ED) attendance and hospital admissions amongst those who have died by suicide in NI.

OBJECTIVES

The study objectives are to examine the relationships between ED attendances, hospital admissions, and death by suicide.

METHODS

A case control methodology was used, drawing on routinely collected administrative data on all deaths by suicide in Northern Ireland between 1/1/2012 and 31/12/2015. Each death was matched to 5 live controls, based on age and gender (n = 6630).

RESULTS

Death by suicide is associated with a recent ED attendance, with the highest odds for those who attended within the past three months (odds = 3.2, 95% CI = 2.5-4.2). Death by suicide is also associated with recent hospital admission, with the highest odds of death for admission within the past three months (odds = 6.6, 95% CI = 5.2-8.3). The odds of suicide are also higher for those living in a more deprived or urban area.

LIMITATIONS

The study is limited to administrative data.

CONCLUSIONS

Staff in EDs and hospitals may have a role in suicide prevention. These findings again support the importance of addressing economic deprivation and other area level factors, such as contagion in suicide prevention strategies.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Death by suicide at the Ward level in Northern Ireland

BACKGROUND

Deaths from suicide, as recorded within the Northern Ireland Coroner's Office for the years 2005-2011 inclusive, were analysed in terms of standardised mortality ratios (SMRs), within Wards and Local Government Districts (LGDs). The aim of the study is to examine factors relating to the ecological context of the area within which the person resided at time of death. Area deprivation, religious composition and age structure are examined in terms of SMRs, while controlling for the number of individuals living within a designated area.

METHODS

Random-intercept Poisson regression models were used in conjunction with empirical Bayes prediction to examine area effects.

RESULTS

Considerable variation occurs between the numbers of recorded deaths within each area. A strong association is shown between deprivation and the number of deaths by suicide within an area. There was considerable variation at the LGD level in terms of the number of deaths, but once the nested nature of Wards was taken into account and adjusted for level of deprivation, the variation between LGD was no longer statistically significant. When adjusted for the number of individuals within each age group, the number of deaths in the younger and middle-aged groups did not show a statistical difference (0.05 level), nor did the religious composition of the area in terms of the number of recorded deaths.

CONCLUSIONS

Based on SMRs, using empirical Bayes prediction, area effects were shown to be substantial, especially in urban locations where there are high rates of deprivation.

DVD Versus Physiotherapist-Led Inhaler Education: A Randomised Controlled Trial

Correct technique with inhalers is vital for therapeutic effect. Efficacy of DVD inhaler instruction was investigated. Secondary aims were to examine feasibility of an inhaler technique outcome measure, and to compare knowledge and self-efficacy after DVD or individual education. This was a randomised controlled trial conducted in a regional hospital paediatric ward, involving new or existing paediatric inhaler users. Inhaler technique was assessed pre-education in existing inhaler users. Participants were then randomised to message equivalent education by DVD or individually with a physiotherapist. Inhaler technique, self-efficacy and knowledge were assessed immediately post- and three months after education. Twenty one participants received DVD or individual education. There were no significant differences between groups for technique, self-efficacy or knowledge at any time. The outcome measure was feasible for use in a research study. DVD education was equivalent to individual instruction to teach parents how to use inhalers with their child.

Factors Associated with Suicide in Four Age Groups: A Population Based Study

Life events and circumstances leading to death change throughout the life course. In this study, 4 age groups within those who have died by suicide are compared in terms method of suicide, sex, occupation, mental disorders, prior suicide attempts, and life events prior to death. Analyses were based on a database of deaths by suicide and undetermined intent based on data in the Northern Ireland (NI) coronial files from 2005-2011 (N  = 1667). Research determined that hanging is very prominent as a method of death within the under-20 age group. Women who die by suicide are more likely to have a known mental disorder than men, and the proportions increase with age group. Relationship difficulties are associated with many of these deaths and particularly for males aged under 40 years. Physical health and life events were more relevant than mental illness per se, in males aged over 61 years. For a sizeable proportion of the cases included in the current database there was no information on the life events prior to death. Understanding the factors associated with suicide across age groups is essential to informing suicide prevention strategy and programs and the development of more nuanced and effective interventions.

Patient experience and overall satisfaction after emergency abdominal surgery

Background

There is a growing recognition of the importance of patient experience in healthcare, however little is known in the context of emergency abdominal surgery. This study sought to quantify the association between patient experience and overall satisfaction.

Methods

Patient demographics, operation details and 30-day clinical outcome data of consecutive patients undergoing emergency abdominal surgery were collected. Data was collected using validated Patient Reported Experience Measures (PREMs) questionnaires. Categorical data were tested using Mann Whitney U test. Multivariable regression was used to determine independent factors associated with satisfaction.

Results

In a well-fitting multivariable analysis (R² = 0.71), variables significantly associated with a higher global satisfaction score were “sufficient information given about treatment” (β = 0.86, 95% CI 0.01–1.70, p = 0.047), "sufficient explanation of risks and benefits of surgery" (β = 1.26, 95% CI 0.18–2.34, p = 0.020), “absence of night-time noise” (β = 1.35, 95% CI 0.56–2.14, p = 0.001) and “confidence and trust in nurses” (β = 1.51, 95% CI 0.54–2.49, p = 0.003).

Conclusions

Overall patient satisfaction was strongly associated with perceptions of good communication and transfer of information. Confidence and trust in the clinical team is an important determinant of patient experience. Improving the ward environment by reducing noise at night may also improve the overall experience and satisfaction in emergency surgery.

Emissions from prescribed burning of agricultural fields in the Pacific Northwest

Prescribed burns of winter wheat stubble and Kentucky bluegrass fields in northern Idaho and eastern Washington states (U.S.A.) were sampled using ground-, aerostat-, airplane-, and laboratory-based measurement platforms to determine emission factors, compare methods, and provide a current and comprehensive set of emissions data for air quality models, climate models, and emission inventories. Batch measurements of PM2.5, volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), and polychlorinated dibenzodioxins/dibenzofurans (PCDDs/PCDFs), and continuous measurements of black carbon (BC), particle mass by size, CO, CO2, CH4, and aerosol characteristics were taken at ground level, on an aerostat-lofted instrument package, and from an airplane. Biomass samples gathered from the field were burned in a laboratory combustion facility for comparison with these ground and aerial field measurements. Emission factors for PM2.5, organic carbon (OC), CH4, and CO measured in the field study platforms were typically higher than those measured in the laboratory combustion facility. Field data for Kentucky bluegrass suggest that biomass residue loading is directly proportional to the PM2.5 emission factor; no such relationship was found with the limited wheat data. CO2 and BC emissions were higher in laboratory burn tests than in the field, reflecting greater carbon oxidation and flaming combustion conditions. These distinctions between field and laboratory results can be explained by measurements of the modified combustion efficiency (MCE). Higher MCEs were recorded in the laboratory burns than from the airplane platform. These MCE/emission factor trends are supported by 1-2 min grab samples from the ground and aerostat platforms. Emission factors measured here are similar to other studies measuring comparable fuels, pollutants, and combustion conditions. The size distribution of refractory BC (rBC) was single modal with a log-normal shape, which was consistent among fuel types when normalized by total rBC mass. The field and laboratory measurements of the Angstrom exponent (α) and single scattering albedo (ω) exhibit a strong decreasing trend with increasing MCEs in the range of 0.9-0.99. Field measurements of α and ω were consistently higher than laboratory burns, which is likely due to less complete combustion. When VOC emissions are compared with MCE, the results are consistent for both fuel types: emission factors increase as MCE decreases.

Days out of role due to common physical and mental conditions: results from the Northern Ireland study of health and stress

PURPOSE

Days out of role due to health problems are a major source of lost human capital. We examined the relative importance of common physical and mental disorders in accounting for days out of role in Northern Ireland using the Northern Ireland Study of Health and Stress (NISHS) WHO World Mental Health (WMH) Survey.

METHODS

Face-to-face interviews were carried out with 4340 respondents (68.4 % response rate). Multiple regression analysis estimated associations of specific chronic physical disorders and mental disorders conditions and comorbidities with days out of role controlling for basic socio-demographics.

RESULTS

Overall, 16.8 % of respondents had at least one day totally out of role in the previous year. The strongest population-level effect was associated with arthritis, which accounted for 23.5 % of all days out of role. The strongest individual-level effects (days out of role per year) were associated with any anxiety disorder (32.3) arthritis (26.1) and pain (22.0). The 11 conditions accounted for 93 % of all days out of role, as measured by population attributable risk proportions (PARPs).

CONCLUSIONS

Common health conditions, including mental disorders, make up a large proportion of the number of days out of role and should be addressed to substantially increase overall productivity.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Mental disorders among college students in the World Health Organization World Mental Health Surveys

BACKGROUND

Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.

METHOD

The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1572) and non-students in the same age range (18-22 years; n = 4178), including non-students who recently left college without graduating (n = 702) based on surveys in 21 countries (four low/lower-middle income, five upper-middle-income, one lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioral and substance disorders were assessed with the Composite International Diagnostic Interview (CIDI).

RESULTS

One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders; 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.

CONCLUSIONS

Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.

Prevalence and predictors of psychotropic medication use: results from the Northern Ireland Study of Health and Stress

BACKGROUND

To identify the predictors of psychotropic medication use and to determine rates and patterns of use in Northern Ireland (NI) among the general population and various subgroups.

METHOD

Analysis of data from the NI Study of Health and Stress, a representative household survey undertaken between 2004 and 2008 with 4340 individuals. Respondents were asked about prescribed psychotropic medication use in the previous 12 months along with a series of demographic questions and items regarding experience of traumatic life events. Mental health disorders were assessed using the World Health Organization's Composite International Diagnostic Interview.

RESULTS

Females, individuals aged 50-64 years old, those who were previously married, and those who had experienced a traumatic lifetime event were more likely to have taken any psychotropic medication. Use of any psychotropic medication in the population in the previous 12 months was 14.9%. Use among individuals who met the criteria for a 12-month mental health disorder was 38.5%. Almost one in ten individuals (9.4%) had taken an antidepressant.

CONCLUSIONS

Compared with other countries, NI has high proportions of individuals using psychotropic medication in both the general population and those who met the criteria for a 12-month mental disorder. However, these results still suggest possible under treatment of mental disorders in the country. In addition, rates of use in those with no disorder are relatively high. The predictors of medication use are similar to findings in other countries. Possible research and policy implications are discussed.