Determinants of accident and emergency attendances and emergency admissions in infants: birth cohort study

BACKGROUND

There is limited understanding of the drivers of increasing infant accident and emergency (A&E) attendances and emergency hospital admissions across England. We examine variations in use of emergency hospital services among infants by local areas in England and investigate the extent to which infant and socio-economic factors explain these variations.

METHODS

Birth cohort study using linked administrative Hospital Episode Statistics data in England. Singleton live births between 1-April-2012 and 31-March-2019 were followed up for 1 year; from 1-April-2013 (from the discharge date of their birth admission) until their first birthday, death or 31-March-2019. Mixed effects negative binomial models were used to calculate incidence rate ratios for A&E attendances and emergency admissions and mixed effects logistic regression models estimated odds ratio of conversion (the proportion of infants subsequently admitted after attending A&E). Models were adjusted for individual-level factors and included a random effect for local authority (LA).

RESULTS

The cohort comprised 3,665,414 births in 150 English LAs. Rates of A&E attendances and emergency admissions were highest amongst: infants born < 32 weeks gestation; with presence of congenital anomaly; and to mothers < 20-years-old. Area-level deprivation was positively associated with A&E attendance rates, but not associated with conversion probability. A&E attendance rates were highest in the North East (916 per 1000 child-years, 95%CI: 911 to 921) and London (876 per 1000, 95%CI: 874 to 879), yet London had the lowest emergency admission rates (232 per 1000, 95%CI: 231 to 234) and conversion probability (25% vs 39% in South West). Adjusting for individual-level factors did not significantly affect variability in A&E attendance and emergency admission rates by local authority.

CONCLUSIONS

Drivers of A&E attendances and emergency admissions include individual-level factors such being born premature, with congenital anomaly and from socio-economically disadvantaged young parent families. Support for such vulnerable infants and families should be provided alongside preventative health care in primary and community care settings. The impact of these services requires further investigation. Substantial geographical variations in rates were not explained by individual-level factors. This suggests more detailed understanding of local and underlying service-level factors would provide targets for further research on mechanisms and policy priority.

Emergency paediatric critical care in England: describing trends using routine hospital data

OBJECTIVE

To determine trends in emergency admission rates requiring different levels of critical care in hospitals with and without a paediatric intensive care unit (PICU).

DESIGN

Birth cohort study created from Hospital Episode Statistics.

SETTING

National Health Service funded hospitals in England.

PATIENTS

8 577 680 singleton children born between 1 May 2003 and 31 April 2017.

OUTCOME MEASURES

Using procedure and diagnostic codes, we assigned indicators of high dependency care (eg, non-invasive ventilation) or intensive care (eg, invasive ventilation) to emergency admissions.

INTERVENTIONS

Children were followed up until their fifth birthday to estimate high dependency and intensive care admission rates in hospitals with and without a PICU. We tested the yearly trend of high dependency and intensive care admissions to hospitals without a PICU using logistic regression models.

RESULTS

Emergency admissions requiring high dependency care in hospitals without a PICU increased from 3.30 (95% CI 3.09 to 3.51) per 10 000 child-years in 2008/2009 to 7.58 (95% CI 7.28 to 7.89) in 2016/2017 and overtook hospitals with a PICU in 2015/2016. The odds of an admission requiring high dependency care to a hospital without a PICU compared with a hospital with a PICU increased by 9% per study year (OR 1.09, 95% CI 1.08 to 1.10). The same trend was not present for admissions requiring intensive care (OR 1.01, 95% CI 0.99 to 1.03).

CONCLUSIONS

Between 2008/2009 and 2016/2017, an increasing proportion of admissions with indicators of high dependency care took place in hospitals without a PICU.

National data opt out programme: consequences for maternity statistics in England

Electronic health records offer great potential for individual care, service improvement and, when collated, the health of the wider population. Datasets composed of these types of records have been invaluable to our understanding of risk factors for maternal and infant ill-health. However, a potential barrier to data quality in England is emerging where patients choose to opt out of sharing their information beyond the NHS. Focussing on maternity statistics, we will present the importance of population level health data for monitoring NHS services, and the potential consequences for patients of opting out. Evidencing the success of similar systems in Nordic countries, we argue that the English population must be better informed of the implications of opting out of sharing NHS data for research and the safeguards in place to protect patient information.

Geospatial and seasonal variation of bronchiolitis in England: a cohort study using hospital episode statistics

BACKGROUND

Rates of hospital admissions for bronchiolitis vary seasonally and geographically across England; however, seasonal differences by area remain unexplored. We sought to describe spatial variation in the seasonality of hospital admissions for bronchiolitis and its association with local demographic characteristics.

METHODS

Singleton children born in English National Health Service hospitals between 2011 and 2016 (n=3 727 013) were followed up for 1 year. Poisson regression models with harmonic functions to model seasonal variations were used to calculate weekly incidence rates and peak timing of bronchiolitis admissions across English regions and clinical commissioning groups (CCGs). Linear regression was used to estimate the joint association of population density and deprivation with incidence and peak timing of bronchiolitis admissions at the CCG level.

RESULTS

Bronchiolitis admission rates ranged from 30.9 per 1000 infant-years (95% CI 30.4 to 31.3) in London to 68.7 per 1000 (95% CI 67.9 to 69.5) in the North West. Across CCGs, there was a 5.3-fold variation in incidence rates and the epidemic peak ranged from week 49.3 to 52.2. Admission rates were positively associated with area-level deprivation. CCGs with earlier peak epidemics had higher population densities, and both high and low levels of deprivation were associated with earlier peak timing.

CONCLUSIONS

Approximately one quarter of the variation in admission rates and two-fifths of the variation in peak timing of hospital admissions for bronchiolitis were explained by local demographic characteristics. Implementation of an early warning system could help to prepare hospitals for peak activity and to time public health messages.

Does adiposity mediate the relationship between socioeconomic position and non-allergic asthma in childhood?

Background

Despite its high prevalence, early onset and chronic nature, the causes of asthma are not clearly established. The present study examined a plausible but untested relationship in the development of non-allergic asthma; an asthma phenotype closely linked to deprivation and other preventable risk factors. Our aim was to determine the mediating role of adiposity in the relationship between socioeconomic position in infancy and non-allergic asthma emergence in mid-childhood.

Methods

To estimate the causal indirect effect of adiposity we applied the parametric g-computational procedure to 6203 singleton children from the UK Millennium Cohort Study. Adiposity was measured at age 7 by body mass index, waist circumference and waist circumference-to-height ratio. Children who developed non-allergic asthma between the age of 7 and 14 were compared with children without allergies or allergic asthma at these ages.

Results

We found no evidence to suggest that adiposity is a mediator in the relationship between socioeconomic position and the development of non-allergic asthma in mid-childhood. After adjustment for risk factors, the direct effect of socioeconomic position remained; children in the lowest tertile of socioeconomic position had a 43% (OR 1.43, 95% CI 1.38 to 1.49) greater odds of developing non-allergic asthma compared with the highest tertile.

Conclusions

Adiposity at age 7 does not mediate the relationship between socioeconomic position and non-allergic asthma. The results suggest that improving socioeconomic conditions and promoting healthy weight are both important in reducing the development of non-allergic asthma in early to mid-childhood.

Mother's education and offspring asthma risk in 10 European cohort studies

Highly prevalent and typically beginning in childhood, asthma is a burdensome disease, yet the risk factors for this condition are not clarified. To enhance understanding, this study assessed the cohort-specific and pooled risk of maternal education on asthma in children aged 3-8 across 10 European countries. Data on 47,099 children were obtained from prospective birth cohort studies across 10 European countries. We calculated cohort-specific prevalence difference in asthma outcomes using the relative index of inequality (RII) and slope index of inequality (SII). Results from all countries were pooled using random-effects meta-analysis procedures to obtain mean RII and SII scores at the European level. Final models were adjusted for child sex, smoking during pregnancy, parity, mother's age and ethnicity. The higher the score the greater the magnitude of relative (RII, reference 1) and absolute (SII, reference 0) inequity. The pooled RII estimate for asthma risk across all cohorts was 1.46 (95% CI 1.26, 1.71) and the pooled SII estimate was 1.90 (95% CI 0.26, 3.54). Of the countries examined, France, the United Kingdom and the Netherlands had the highest prevalence's of childhood asthma and the largest inequity in asthma risk. Smaller inverse associations were noted for all other countries except Italy, which presented contradictory scores, but with small effect sizes. Tests for heterogeneity yielded significant results for SII scores. Overall, offspring of mothers with a low level of education had an increased relative and absolute risk of asthma compared to offspring of high-educated mothers.

Note: A simple, convenient, and reliable method to prepare gold scanning tunneling microscope tips

A simple method to prepare gold tips for scanning tunneling microscopy has been introduced. In this method, electrochemical etching without a hazardous electrolyte was employed. The setup uses basic laboratory instrumentation to control the etching process. This avoids purchasing complicated, expensive, and dedicated equipment for tip preparation. A procedure to optimize the etching parameters by setting the current limit is described. Etched tips were checked with both optical and scanning electron microscopy.

A novel explosive process is required for the γ-ray burst GRB 060614

Over the past decade, our physical understanding of gamma-ray bursts (GRBs) has progressed rapidly, thanks to the discovery and observation of their long-lived afterglow emission. Long-duration (> 2 s) GRBs are associated with the explosive deaths of massive stars ('collapsars', ref. 1), which produce accompanying supernovae; the short-duration (< or = 2 s) GRBs have a different origin, which has been argued to be the merger of two compact objects. Here we report optical observations of GRB 060614 (duration approximately 100 s, ref. 10) that rule out the presence of an associated supernova. This would seem to require a new explosive process: either a massive collapsar that powers a GRB without any associated supernova, or a new type of 'engine', as long-lived as the collapsar but without a massive star. We also show that the properties of the host galaxy (redshift z = 0.125) distinguish it from other long-duration GRB hosts and suggest that an entirely new type of GRB progenitor may be required.

Method for determination of pentobarbital in dry dog food by gas chromatography/mass spectrometry

A procedure has been developed and validated for measuring the concentration of pentobarbital residues in dry, extruded animal feed in the range of 3-200 ng/g (ppb) with an estimated limit of quantitation of 2 ppb. The method was developed for surveillance purposes: to measure the concentration of euthanizing agent which might be present in feeds incorporating rendered products which themselves might include some fraction of euthanized animals. A previously published qualitative procedure was modified by adding isotopically labelled pentobarbital as an internal standard. Dry feed was ground and extracted with methanol. The extract was loaded on a mixed-mode (C-18, anion exchange) solid-phase extraction cartridge designed for barbiturate residues. Pentobarbital was eluted and derivatized for gas chromatography/mass spectrometry in positive ion chemical ionization mode. Quantitation was based on the ratio of dimethyl-pentobarbital MH+ (m/z 255) vs dimethyl-pentobarbital-d(5) (m/z 260) in standards and extracts. Accuracy ranged from 112% at 3 ppb to 96% at 200 ppb, with relative standard deviations ranging from 4% at 3 ppb to 2% at 200 ppb.

Association of sex of the fetus in isolated fetal choroid plexus cysts

We sought to determine if an association exists between sex of the fetus and the finding of isolated fetal choroid plexus cysts. Of 131 fetuses, 62 were male (47.3%) and 69 were female (52.7%). No statistically significant differences were found in the maternal demographic parameters studied (age, race, gravidity, parity, sonogram timing) or descriptive cyst information obtained (location, number, dimensions, resolution), although bilaterality was more common in male fetuses. The determination that isolated choroid plexus cysts are seen equally frequently in male and female fetuses adds to basic information about such a common sonographic finding.

Glycosylated hemoglobin as a predictor of fetal pulmonic maturity in insulin-dependent diabetes at term

In insulin dependent diabetic (IDDM) gestations, fetal pulmonary maturity is delayed in the presence of suboptimal glycemic control. Serum glycosylated hemoglobin (HbA1c) provides a means of assessing glycemic control. We evaluated maternal HbA1c in IDDM pregnancies at term undergoing amniocentesis for lung maturity to establish if euglycemia is associated with improved fetal lung maturity. Between July 1995 and June 1996, IDDM patients undergoing amniocentesis at term for lung maturity studies had a maternal serum sample analyzed for HbA1c. Fetal lung maturity was established by the presence of phosphatidylglycerol (PG) in amniotic fluid. HbA1c was considered elevated if >6.2%. Mean HbA1c level was 6.8% (range 4.4 to 9.9%). PG was present in 54% of patients with elevated HbA1c (7/13) versus 80% of those with normal HbA1c (8/10) (p = 0.4). Although birth weight was higher in the elevated than in the normal HbA1c group (3770 +/- 514 vs. 3215 +/- 610 g), no association was present between birth weight and HbA1c level (r = 0.22, p = 0.4). The rate of a mature pulmonic profile at term is not significantly different between IDDM women with good or poor glycemic control. HbA1c values should not be used to predict the presence or absence of amniotic fluid PG.

The risk of infection with HIV and hepatitis B in individuals who inject steroids in England and Wales

Data on injecting anabolic steroid users, within the national Unlinked Anonymous HIV Prevalence Monitoring Survey of injecting drug users (IDUs) were analysed to determine their risk of acquiring blood borne viruses. One hundred and forty-nine participants who had injected anabolic steroids in the previous month were identified from 1991-6, contributing 1.4% of all participation episodes in the survey. Rates of needle and syringe sharing by steroid users were low. Three of the 149 (2.0%) had anti-HBc and none had anti-HIV in their salivary specimens. The prevalence of anti-HBc in steroid injectors was significantly lower than in heroin injectors, 275/1509 (18%) (P < 0.001), or in amphetamine injectors, 28/239 (12%) (P < 0.001). The risk of blood borne virus transmission amongst these steroid injectors is low, probably due to hygienic use of injecting equipment and low levels of sharing. It is important to distinguish steroid injectors from other IDUs because they are a distinct group in terms of lifestyle and injecting practice.

Complications of intrauterine placement of a vesicoamniotic shunt

BACKGROUND

Fetal obstructive uropathies complicated by severe oligohydramnios can cause neonatal death due to renal dysplasia and pulmonary hypoplasia.

CASE

A 31-year-old multigravida was referred at 19.6 weeks with sonographic evidence of fetal megacystis and bilateral hydroureteronephrosis, and severe oligohydramnios. A vesicoamniotic shunt was placed for urinary diversion. Complications included shunt migration, intestinal evisceration, amniorrhexis, preterm labor, and preterm delivery. Bowel characteristics were assessed by measuring the intestinal lumen diameter for evidence of obstruction. The lumen diameter remained stable at 3-5 mm, and the luminal wall remained stable at 2.5 mm. After birth at 31 weeks, the infant underwent exploratory laparotomy and extraction of malpositioned shunts, vesicostomy, and closure of abdominal wall defect. He was discharged at 61 days of life after resolution of neonatal pulmonary and infectious complications.

CONCLUSION

Operative management of complete fetal obstructive uropathy is beneficial despite potential complications.

Prenatal diagnosis of an infant with mosaic trisomy 16 of paternal origin

We present the first case of an infant with paternally-derived mosaic trisomy 16. Amniocentesis following an elevated maternal serum alpha-fetoprotein level and early fetal growth restriction at 19 weeks detected a high level of mosaicism with 25/33 colonies demonstrating trisomy 16 and 8/33 colonies with a normal 46,XX karyotype. Molecular studies revealed a paternal origin of the trisomy which was present in amniotic fluid cells, representing either a post-zygotic error or a meiosis II non-disjunction without crossing-over. In addition, there was normal biparental inheritance in the normal cell line. The symmetrically growth-restricted fetus was closely monitored for the remainder of the gestation. Decreased fetal movements at 36 weeks in conjunction with electronic fetal monitoring showing evidence of fetal distress necessitated abdominal delivery. Severe growth restriction, mild facial dysmorphism, and cardiac anomalies were identified. Microsatellite analysis demonstrated biparental inheritance in skin fibroblasts with a paternal origin for the trisomy in the placenta. Follow-up cytogenetic studies of additional tissues revealed 85 per cent trisomy 16 mosaicism in the placenta, yet only cytogenetically normal cells in lymphocytes and fibroblasts.

Mid-trimester prenatal sonographic diagnosis of a pericardial cyst

Prenatal diagnosis of pericardial masses are infrequent and usually consist of intrapericardial teratomas or haemangiomas. We present the first report of prenatal diagnosis of a suspected pericardial cyst at 14 weeks' gestation which was subsequently confirmed by neonatal computed tomography.

Prenatal color and pulsed Doppler sonographic documentation of intrathoracic umbilical vein and ductus venosus, confirming extensive hepatic herniation in left congenital diaphragmatic hernia

Prenatal sonographic diagnosis of an unusual case of a large left congenital diaphragmatic hernia is presented. The fetal stomach was located within the right thorax, posterior to the dextropositioned heart. Color and pulsed Doppler ultrasonography documented intrathoracic umbilical vein and ductus venosus vessels and respective waveforms, confirming extensive herniation of the left hepatic lobe.

Computer automated sperm head morphometry analysis (ASMA) of goat spermatozoa

The development of computer automated sperm morphometry analysis (ASMA) allows for the objective analysis of sperm head dimensions. A number of studies have been performed to optimize the efficiency of these systems when analyzing spermatozoa from a variety of species. In this study, frozen semen from 10 fertile goat bucks was thawed and prepared on slides for morphometric analysis to evaluate technical variation and to standardize ASMA procedures for goat spermatozoa. Methods of staining, the number of spermatozoa necessary to sample and optimal microscopic magnification were assessed. Staining for 20 min in hematoxylin (HEM) was found to be optimal. The most efficient method of analyzing goat sperm morphometry was to evaluate 100 sperm cells at x20 objective magnification. Using these techniques, a sample could be analyzed in approximately 2 min. The system properly recognized and digitized spermatozoa 96% of the time with a target recognition error rate of less than 1%. The morphometric measurements of sperm heads for all 10 bucks were the following: length = 7.69microm, width = 3.80microm, width/length ratio = 0.5, area = 22.82microm and perimeter = 20.15microm. The mean coefficients of variation (CV) for all bucks ranged from 3.4% for length to 5.8% for area. Standardized sample preparation techniques and analysis were found to improve the efficiency of ASMA.

Effects of dietary testosterone on growth and sex ratio in juvenile Atlantic salmon (Salmo salar)

Diets to which testosterone (1 or 10 ng/g diet) had been added were fed to juvenile Atlantic salmon (Salmo salar) for nine months beginning for months after hatching (Experiment 1) and upon completion of yolk absorption (Experiment 2) to determine the effects on growth, gonadal development, and sex ratio. Dietary testosterone at 10 ng/g fed to juvenile salmon at four months after hatching (Exp. 1) induced significant changes in condition factor (0.69±0.01) compared to controls (0.79±0.01) at the end of the test period. In both experiments, salmon treated with 10 ng/g diet induced a significantly higher percentage of male fish compared to controls. Dietary testosterone at 1 ng/g fed to juvenile salmon beginning four months after hatching induced significant increases in weight (18.95±0.99) and length (13.58±0.23) compared to controls (14.55±1.50 and 11.94±0.43, respectively). In Experiment 1 or 2, there was no apparent influence of dietary testosterone on precocious male sexual development. Dietary testosterone at 1 or 10 ng/g fed to juvenile salmon upon completion of yolk absorption (Exp. 2) induced no consistent changes in growth in juvenile Atlantic salmon. These studies indicate that low levels of dietary testosterone may influence physiological responses in juvenile Atlantic salmon dependent upon timing of treatment.

Monoclonal antibodies against a component related to soluble estrogen receptor

Mice were immunized with 1 to 3 micrograms of cytoplasmic estrogen receptor fragment purified from human myometrium by affinity chromatography. Two RE-antibody-secreting clones were detected from one fusion that were capable of precipitating cytosol RE. Monoclonal antibody D5 (subclass IgG1) reacts with an antigen that is related to RE from immunoprecipitation studies but which can be separated from the hormone binding unit. In the presence of anti-mouse serum, D5 precipitates labeled human cytoplasmic RE complexes from breast tumor, fibroid, myometrial, and endometrial preparations but does not react with nuclear RE from human endometrium or cytoplasmic RE from other species tested. Conversely, antibody C3 (Class IgM) precipitates human cytoplasmic RE and nuclear RE complexes as well as labeled cytoplasmic RE from rat and calf uterus and chick oviduct. Neither antibody reacts with progesterone receptor or androgen receptor from human breast tumor, SHBG from human plasma, or rat alpha-fetoprotein. With D5, steroid labeling of cytoplasmic RE at 25 degrees increased the RE immune complex precipitated. D5 precipitates molybdate-stabilized RE from myometrial cytosol when labeled at 25 degrees but not at 4 degrees. C5 precipitates molybdate-stabilized RE whether cytosol was steroid-labeled at 4 degrees or 25 degrees. For D5, optimal precipitation of RE from human breast tumor was observed when cytosol was steroid-labeled at 25 degrees in buffers of pH range 5 to 6. Immunochemical studies indicate that D5 is associated with a Mr 29,000 component in RE-positive cytosols. Electrofocusing and sucrose density gradient analysis confirmed that D5 antigen is a non-hormone-binding component related to cytosolic RE from breast tumor and myometrium.

Immunoradiometric studies with monoclonal antibody against a component related to human estrogen receptor

A human specific monoclonal antibody (D5) raised against a Mr 36,000 cytosolic estrogen receptor component (RE) partially purified from human myometrium was used to develop a simple, rapid, and sensitive solid-phase immunoradiometric assay (IRMA) for the reactive antigen in tissue cytosols from breast tumors, myometrium, endometrium, and endometrial carcinomas. The IRMA did not detect antigen in RE-negative cytosols from human breast tumors and endometrial carcinomas. RE-positive cytosols from chick oviduct and calf and rat uteri failed to produce an IRMA response. A pilot study indicated a significant correlation (P less than 0.001) between D5 IRMA value and RE sites in breast tumors assayed by [3H]estradiol binding sites. The presence of D5 antigen was dependent on the presence of cytosolic RE but not progesterone receptor. RE-positive patients age 50 years and over demonstrated significantly higher D5 assay values than did patients under 50 years. The data suggest that the D5 antigen is a component of the estrogen receptor or coordinately regulated with the receptor in human cells and that the assay method may have clinical use.

pKa values of estrone, 17 beta-estradiol and 2-methoxyestrone

The acid ionization constants of estrone (10.77), 17 beta-estradiol (10.71) and 2-methoxyestrone (10.81) have been determined spectrophotometrically and shown to be consistent with the additivity of substituent effects of the phenol ring. Previously published values for estrone (10.914) and 17 beta-estradiol (10.078) are shown to be incorrect, at variance with the established trend for phenols, and inconcsistent with the similarity of the compounds.