Attendant Reduction Research Articles

PWE-127 The Extended Effect of An Alcohol Liaison Nurse Service on Attendance at A County’s Emergency Departments: A 3 Year Retrospective Cohort Study

Introduction Worcestershire Acute Hospitals NHS Trust has an Alcohol Liaison Nurse Service (ALNS) across two hospital sites, with two full-time ALNs providing screening, case management support, brief interventions (BI) and referrals into community treatment services. We performed a retrospective cohort study to assess the impact of the ALNS on emergency departement (ED) re-attendance over a 3 year period and estimated the cost saving using the 2012/3 reference costs. Methods All patients who had attended the ED, surgical or medical assessment units and received a BI delivered by the ALNS over a 3 month period, between January to March 2012, was identified via hospital records (Patient First ED computer system and OASIS). Patient attendances to ED for the preceding 12 month period were compared with the 12 month periods after the BI over the following 3 years. Patients were excluded if they lived outside the trust catchment area or were imprisoned or died during the study period. Costs of attendances to ED over the period were estimated as £114 per visit. Statistical analysis was by paired t-test. Results 192 patients (123 males & 69 females) identified as having a BI were included in the cohort. 36 were excluded due to death within the study period and 4 due to incarceration. The median age of the cohort was 44 years (range 17–87 years). The most common reason for presentation related to mental health issues including deliberate self harm and overdose. During the 12 month period before ALNS intervention there were 464 qualifying ED attendances with an average of 2.42 attendances per patient. In the first 12 months following BI, the ED attendance rate fell to 327 (1.7 attendances/patient), and then to 255 in the second 12 months (1.33 attendances/patient), and finally 225 in the third 12 months following BI (1.17 attendances/patient). The reduction in attendance was statistically significant 12 months after intervention compared with the preceding year (p For this 3 month cohort of 192 patients, the cost of ED attendance in the year before BI was estimated at £52, 896. By the end of the study period this had been reduced by 51.5% (twelve monthly cost estimates £37,278, £29,070 and £25,650). Conclusion This pragmatic study suggests that an ALNS may have a sustained effect upon the number and cost of ED attendances. Reference 1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/261154/nhs_reference_costs_2012-13_acc.pdf Disclosure of Interest None Declared

Impact of integrated health system changes, accelerated due to an earthquake, on emergency department attendances and acute admissions: a Bayesian change-point analysis

ObjectiveTo chart emergency department (ED) attendance and acute admission following a devastating earthquake in 2011 which lead to Canterbury's rapidly accelerated integrated health system transformations.DesignInterrupted time series analysis, modelling using...

Public health structures attendance during the Ebola outbreak in Guéckédou, Guinea.

The Ebola virus disease (EVD) outbreak in West Africa may affect healthcare attendance. We describe, in the Guinean prefecture of Guéckédou, trends in attendance of public healthcare structures and the main reported diagnoses over the year following the EVD outbreak notification (March 2014). Monthly numbers of visits and main diagnoses such as malaria, schistosomiasis and measles reported by Guéckédou health centres and health posts were described from January 2012 to March 2015. The median number of visits was 15 724/month. From 1 April to 30 September 2014 (EVD outbreak peak), 90 947 visits were reported, representing decreases of 4·8% and 7·4% compared to 2013 and 2012, respectively. Following December 2014 (last EVD notification in Guéckédou), visits increased from 12 540 in January to 16 032 in March 2015. Malaria seasonality was observed in 2014 with 22 519 notifications from 1 April to 31 July. No seasonality was observed for intestinal schistosomiasis (median 485 cases/month); however, a peak was notified in March 2014 (824 cases). Over the study period, all measles cases were notified in 2015 (183 cases). Reduction in healthcare attendance in Guéckédou was modest during the EVD outbreak. Enhanced infectious disease surveillance is a challenge in this context, due to the impact of EVD on traditional prevention programmes.

Effect of thinning and soil treatments on Pinus ponderosa plantations: 15-year results

Thinning with removal of whole trees in a plantation or natural forest stand raises two main concerns – soil compaction from the ground-based machinery and nutrient depletion particularly with whole tree harvest as is often practiced for attendant fuels reduction. To address these concerns, two sets of experimental treatments were imposed in young ponderosa pine plantations. In the first set, we applied four treatments to test the effects of thinning with biomass removal using progressively more soil manipulations: (I) control, (II) thinning only with all biomass removed, (III) same as (II) but followed by sub-soiling in traffic lanes, and (IV) same as (III) but with nitrogen and phosphorus fertilization within traffic lanes prior to sub-soiling. In the second experiment set we applied four combination treatments to test the further effects of soil manipulations with wood chips and fertilizer on traffic lanes. In thinned stands: (i) the harvested trees were chipped, and spread onto traffic lanes followed by sub-soiling and rototilling, (ii) same as (i) but traffic lanes also received N and P with the chips prior to the sub-soiling, (iii) traffic lanes were sub-soiled, then thinning chips were returned to just the surface of traffic lanes, and (iv) same as (iii) but traffic lanes also received N and P fertilizer with the chips. Tree height and diameter were measured three times, starting immediately following treatments and again at 5 and 15years post-treatment. In addition, soil bulk density was measured at 6years and soil chemistry (C, N, and P) was measured at 6 and 16years. Our results indicate: (1) thinning by itself with no subsoiling did not compact the soils, but increased growth rate of residual trees, although the periodic annual increment of basal area and volume was still higher in the control than other main-plot treatments; (2) neither subsoiling nor rototilling, both of which might mitigate soil compaction, enhanced tree growth; (3) short-term plantation growth was not improved with chip returns or chips with fertilization; (4) since thinning and soil treatments showed more insect damage and higher mortality, any management operations that involve cutting or damaging trees or roots should be avoided during active periods of bark beetle flight; (5) both thinning and soil treatments did not reduce carbon sequestration in the mineral soils. A lack of growth benefits from returning thinning chips, rototilling, and direct fertilization for a longer period appeals to further study.

Does family-centred neonatal discharge planning reduce healthcare usage? A before and after study in South West England

ObjectiveTo implement parent-oriented discharge planning (Train-to-Home) for preterm infants in neonatal care.DesignBefore and after study, investigating the effects of the intervention during two 11-month periods before and after implementation.SettingFour local...

A study on the effectiveness of E-Mental Health in the treatment of psychosis: Looking to recovery

IntroductionAn integrated program (Institutional Psychiatric Open Light Treatment) for psychosis and personality disorder was enriched with audiovisual functions provided through a dedicated website.The aim of the present study was to observe how and if these added functions support the patients in their daily living, influencing the quality of the recovery process.Recent studies highlighted how telemental health services are effective to provide access, improve basic outcome, facilitate empowerment of patients and be well-accepted (Hilty, 2013; Hailey, 2008) and how integrated community-based treatment, such as Community-Based Psychodynamic Treatment Program (Chiesa and Fonagy, 2009) or Assertive Community Treatment (Veldhuizen and Bahler, 2013) are effective in SMI.Telemental health services may become factors improving real-life functioning, integrating community-based treatment for psychosis and bettering social cognition, functional capacity, resilience, internalized stigma and engagement with mental health services, so positively affecting outcomes of psychosis treatment.MethodsAll patients admitted (May 2010–April 2015) were included. Aged between 18 and 65, with schizophrenia, psychosis, schizoaffective disorder, bipolar disorder, personality disorder.Some troubles with the website use (Voice2Voice) led to a second version, more friendly and simple to use (app2gether).App2gether provided several functions: audio/video conference rooms for patients or family (synchronous virtual space to interact, at scheduled time, with a psychologist, a psychiatrist or a peer support worker, in free groups); chat (asynchronous virtual space for any question or information).We considered primary outcomes proposed by Cochrane Collaboration (Shek, 2010): hospital admissions, days of hospitalization, day-hospital admissions, day-program attendance (e.g. weekly), treatment compliance (voluntary discharge or missing scheduled date).We considered, as secondary outcomes, variables closely associated with real-life functioning (Galderisi, 2015): global functioning (Italian translation of Global Assessment of Functioning Scale), quality of life (Short Form 36 item), social relationships (Personal and Social Performance), internalized stigma (Internalized Stigma Mental Illness Inventory), empowerment (Empowerment Scale).Patients were divided into four cohorts:– 1-using “app2gether” functions in the follow-up, attending day treatment program (n = 35);– 2-attending day treatment program (n = 52);– 3-attending transitional day-hospital program (n = 171);– 4-not included in the IPOLT-program (n = 188).Patients were included in the first group only based on their basic computer skills and fast Internet availability.ResultsAt first, we compared (2) and (3) with (4), as control group. For each patient, we considered an identical observation period before and after day-hospital admission (ANOVA, P < 0.05).We found a significant improvement in primary outcomes and global functioning, but not in other secondary outcomes, for the groups (2) and (3) compared with (4).Over 6-months observation, patients using “app2gether” functions in the follow-up showed:– a significantly decrease in hospital admissions and hospitalization length, compared to non-IPOLT-program group;– a reduction in day-hospital admissions and day-hospital attendance, compared to (2) and (3) groups;– a notable effect on secondary outcomes, compared to all other groups.ConclusionA dedicated website in the IPOLT-program supports patients in their living's place, does not interfere with daily activities, decreases social costs, encourages community integration and reduces stigma.Synchronous telepsychiatry allow a professionally modulated intervention in “here and now”; asynchronous contacts with specialists combine professional intervention with chances of autonomy and autoregulation. These services reduce costs, in terms of FTE (Full Time Equivalent), but not the efficacy.Future advances in the websites should be designed, simplifying the contact surface with the treating-team and reducing the social impact of therapeutic practice.A better understanding of the complex variables influencing real-life functioning and new sensitive tools to detect it are needed.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Preparing for Home: a before-and-after study to investigate the effects of a neonatal discharge package aimed at increasing parental knowledge, understanding and confidence in caring for their preterm infant before and after discharge from hospital

BackgroundImproved survival and shorter length of stay (LOS) for preterm infants, together with poorly organised discharge planning in some neonatal units, leaves many parents ill prepared to take their babies home, with increased use of out-of-hours services. Despite the importance accorded to family-orientated neonatal care by the Department of Health and the National Institute for Health and Care Excellence, few neonatal units offer structured, family-orientated discharge planning.ObjectivesTo implement a parent-orientated discharge planning approach (Train-to-Home package) for preterm infants and investigate the effects on parental self-efficacy scores, infants’ LOS and change in costs associated with use of health-care resources in the 8 weeks after discharge, before and after implementation.DesignA before-and-after study, investigating the effects of Train-to-Home package during two 11-month periods, immediately before and after its implementation.SettingFour local neonatal units in South West England.ParticipantsInfants without major anomalies, born at 27–33 weeks’ gestation, admitted to the participating units, and their parents.Train-to-Home interventionA parent-orientated package that incorporated approaches to improving parents’ involvement in, and understanding of, their baby’s needs. It comprised a train graphic and supporting care pathways to facilitate parents’ understanding of their baby’s progress through the neonatal unit, combined with improved estimation, soon after hospital admission, of the baby’s likely discharge date.Main outcome measuresPrimary – Perceived Maternal Parenting Self-Efficacy (PMPS-E) scores before and after implementing the Train-to-Home package; secondary – infant LOS and health-care utilisation after discharge.ResultsWe recruited 128 and 117 infants, respectively, in phase 1 (before implementation) and phase 2 (after implementation). In phase 2, parents reported improved understanding of babies’ progress, and preparedness for discharge, although PMPS-E scores did not change. The number of visits to emergency departments (EDs) fell from 31 in phase 1 to 20 in phase 2 (p < 0.05), with a significant reduction in associated health-care costs (from £3400 to £2200;p < 0.05) after hospital discharge. LOS did not change, but in both phases of the study > 50% of infants went home at > 3 weeks before their estimated date of delivery. Many nurses felt that the estimated discharge dates were over-optimistic, despite being based upon recent local data, and accurately predicting discharge dates for almost 75% of babies in the study.HarmsNo adverse consequences were identified.ConclusionsThe very early discharge of most babies made further shortening of LOS very difficult to achieve. Despite the lack of change of the parental self-efficacy scores, parents reported that their understanding and confidence in caring for their infants were improved by the Train-to-Home package, and the reduction in ED attendance and associated costs supports this assessment. The present study was limited by the tight time constraints for implementation, limited cascading of staff training and lack of staff confidence in the estimated dates of discharge.Future workProvision of the Train-to-Home package as a web-based system, allowing individual neonatal units and parents to access and use the materials, may allow more effective implementation in the future.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Formation of diamondiferous kyanite–eclogite in a subduction mélange

Diamond- and kyanite-bearing eclogites from the Lace kimberlite on the Kaapvaal craton have common picritic to gabbroic oceanic protoliths with bimineralic eclogites, lying on arrays of Eu∗ and ∑REE that are consistent with accumulation and fractionation of plagioclase and olivine. However, they also show significant compositional differences, such as more grossular-rich garnet and aluminous clinopyroxene (cpx), which require the operation of additional processes. Their nature is elucidated using mineral major- and trace-element compositions, as well as Sr isotope ratios determined by in situ techniques.Highly variable major-element compositions across the co-genetic eclogite suites exert a strong effect on the trace-element distribution between garnet and cpx, whereby Sc, Ge, Sr, Y, Cd, REE, Th and U partition more strongly into garnet with increasing grossular-content. Thus, significant differences between the trace-element compositions of garnet can ensue from crystal-chemical effects alone, making their use as petrogenetic indicators potentially ambiguous. After correcting for these compositional effects, garnet in kyanite-/diamond eclogites, and in eclogites devoid of accessory minerals but with similar signatures, shows depletion (or dilution) in Sc, Ge, Y, In, Zr, Hf and the HREE, and enrichment in the LREE and Th compared to garnet in bimineralic eclogites. This is interpreted as the signature of a pelite-derived melt, which was transferred by addition of aluminous cpx that later exsolved kyanite and garnet, as observed in other aluminous eclogite suites. Continental input can explain initial (at 2.9Ga) 87Sr/86Sr⩾0.714 measured in cpx in eleven samples with low 87Rb/86Sr (<0.01). The association of diamond with kyanite suggests that diamond formation is also linked to this event, possibly due to diamond formation by oxidation of reduced carbon, such as methane, and attendant reduction of Fe3+ in garnet.This model of sediment melt–oceanic crust interaction reconciles evidence for both low- and high-pressure igneous processes in some aluminous eclogites. We suggest that a subduction mélange is a favourable setting for the transfer of a sediment-derived signature into oceanic crust, leading to formation of diamondiferous kyanite–eclogites from bimineralic eclogites. Diapirism, fluxed by the presence of partial melt, may have facilitated dispersal of the eclogites in the lithosphere column, consistent with their widely varying equilibration pressures ranging from ∼5 to 8GPa.

The impact of the 2014–15 Ebola virus disease epidemic on emergency care attendance and capacity at a tertiary referral hospital in Freetown, Sierra Leone: a retrospective observational study

BackgroundThe Ebola virus disease epidemic in West Africa has infected 28 457 people and claimed more than 11 000 lives. Many more people may have died from the indirect effects of the epidemic and closure of normal health-care facilities. Unlike other facilities in West Africa, the emergency department in Connaught Hospital, Freetown, Sierre Leone, protected by an onsite Ebola holding unit, continued to provide emergency care throughout the outbreak. We aimed to assess the effect of the outbreak on emergency department attendance and presentation. We also analysed emergency care capacity across Freetown. MethodsAttendance data from the emergency department and Ebola holding unit at Connaught Hospital were collected from June 1, 2014, to June 1, 2015. Severity of presentation was derived from South African Triage Score (SATS) assigned at first presentation to the emergency department. A mean severity score was calculated by dividing the number of presentations with a SATS of 1–2 by the total number of presentations. Local prevalence of the disease was counted as RT-PCR positive cases at the Ebola holding unit. Emergency care capacity was assessed at the seven principal hospitals in Freetown in May, 2013, and in April, 2015, with a standardised tool, the Emergency Care Capacity Score (ECCS), specifically designed for the low-income setting. All data were collected in Excel (2013). Stata (version 13) was used for statistical analysis. Findings8935 patients presented to the emergency department; mean attendance was 172 patients per week (95% CI 153–191), with attendance varying from 41 patients in the week beginning July 28, 2014, to 284 patients in the week beginning May 11, 2015. Emergency department attendance had a negative correlation with local prevalence of Ebola virus disease (r=–0·640, p<0·0001) (appendix). The proportion of severe cases also varied from a peak of 26·5% in week 40 of 2014 (a period of high local prevalence, 74·6%) to 3·2% in week 28 of 2014 before any case had occurred in Freetown. The mean severity of presentation was 11·9% (95% CI 10·3–13·4). The ECCS was reduced across all domains except the systems domain (appendix). Total ECCS for all seven hospitals decreased by 10% from 2013 to 2015, and all facilities showed a decrease in their individual ECCS score. InterpretationThe reduction in attendance probably demonstrates both a change in health-seeking behaviour—ie, great public fear of hospitals because of the perceived risk of nosocomial transmission of the virus—and a reduction in access to care. The decrease in emergency care capacity was expected and reflects the closure of many health services other than those for Ebola virus disease. Overall, this is an important case study of the impact of an infectious disease outbreak on a tertiary referral hospital in a low-income setting. FundingNone.

Reversing subcellular remodelling in the rescue of depressed contractility

Systolic heart failure with reduced ejection fraction has long been regarded as a heart with an irreversible depression in myocardial contractility. Improvements in ventricular function with recovery of contractility, however, have occurred during a period of cardiac unloading provided by a continuous-flow left ventricular assist device. The authors briefly review subcellular remodelling involved in the appearance of depressed cardiomyocyte work. Redox-sensitive deiodinase 3 (Dio3) is held responsible for a reduction of intracellular thyroid hormone signalling with the re-expression of a fetal gene program that includes slow β-myosin heavy chain. The attendant reduction in contractile work is an adaptation that preserves myocyte efficiency (work/energy consumed) and viability. Neutralizing oxidative stress and Dio3 is integral to the reversal of subcellular remodelling and rescue of depressed contractility.

Division of labour: how does folate metabolism partition between one-carbon metabolism and amino acid oxidation?

One-carbon metabolism is usually represented as having three canonical functions: purine synthesis, thymidylate synthesis and methylation reactions. There is however a fourth major function: the metabolism of some amino acids (serine, glycine, tryptophan and histidine), as well as choline. These substrates can provide cells with more one-carbon groups than they need for these three canonical functions. Therefore, there must be mechanisms for the disposal of these one-carbon groups (when in excess) which maintain the complement of these groups required for the canonical functions. The key enzyme for these mechanisms is 10-formyl-THF (tetrahydrofolate) dehydrogenase (both mitochondrial and cytoplasmic isoforms) which oxidizes the formyl group to CO2 with the attendant reduction of NADP(+) to NADPH and release of THF. In addition to oxidizing the excess of these compounds, this process can reduce substantial quantities of NADP(+) to NADPH.

Leukotriene receptor antagonists as maintenance and intermittent therapy for episodic viral wheeze in children.

Episodic viral wheeze (EVW) associated with viral respiratory tract infections is a common reason for pre-school children to utilise health care resources and for carers to take time away from employment. About a third of children experience a wheezing episode before the age of five years. EVW therefore represents a significant public health problem. Many pre-school children only wheeze in association with viral infections and in such cases EVW appears to be a separate entity from atopic asthma. Some trials have explored the effectiveness of leukotriene receptor antagonists (LTRAs) as regular (maintenance) or episodic (intermittent) treatment in this context. To evaluate the evidence for the efficacy and safety of maintenance and intermittent LTRAs in the management of EVW in children aged one to six years. We searched the Cochrane Airways Group register of trials with pre-specified terms. We performed additional searches by consulting the authors of identified trials, online trial registries of manufacturers' web sites, and reference lists of identified primary papers and reviews. Search results are current to June 2015. We included randomised controlled trials with a parallel-group or cross-over (for intermittent LTRA only) design. Maintenance was considered as treatment for more than two months and intermittent as less than 14 days. EVW was defined as a history of at least one previous episode of wheezing in association with a viral respiratory tract infection in the absence of symptoms between episodes. As far as possible, relevant specific data were obtained from authors of studies that included children of a wider age group or phenotype. Two authors independently assessed studies for inclusion in the review and assessed risk of bias. The primary outcome was number of children with one or more viral-induced episodes requiring one or more treatments with rescue oral corticosteroids. We analysed combined continuous data outcomes with the mean difference and dichotomous data outcomes with an odds ratio (OR). We identified five studies eligible for inclusion in the review (one investigated maintenance treatment, three intermittent therapy and one had both maintenance and intermittent treatment arms) these included 3741 participants. Each study involved oral montelukast and was of good methodological quality, but differed in choice of outcome measures thus limiting our ability to aggregate data across studies. Only primary outcome and adverse event data are reported in this abstract.For maintenance treatment, specific data obtained from a single study, pertaining to children with only an EVW phenotype, showed no statistically significant group reduction in the number of episodes requiring rescue oral corticosteroids associated with daily montelukast versus placebo (OR 1.20, 95% CI 0.70 to 2.06, moderate quality evidence).For intermittent LTRA, pooled data showed no statistically significant reduction in the number of episodes requiring rescue oral steroids in children treated with LTRA versus placebo (OR 0.77, 95% CI 0.48 to 1.25, moderate quality evidence). Specific data for children with an EVW phenotype obtained from a single study of intermittent montelukast treatment showed a small, but statistically significant reduction in unscheduled medical attendances due to wheeze (RR 0.83, 95% CI 0.71 to 0.98).For maintenance compared to intermittent LTRA treatment no data relating to the primary outcome of the review were identified.There were no other significant group differences identified in other secondary efficacy outcomes for maintenance or intermittent LTRA treatment versus placebo, or maintenance versus intermittent LTRA treatment. We collected descriptive data on adverse events as reported by four of the five included studies, and rates were similar between treatment and placebo groups.Potential heterogeneity in the phenotype of participants within and across trials is a limitation of the evidence. In pre-school children with EVW, there is no evidence of benefit associated with maintenance or intermittent LTRA treatment, compared to placebo, for reducing the number of children with one or more viral-induced episodes requiring rescue oral corticosteroids, and little evidence of significant clinical benefit for other secondary outcomes. Therefore until further data are available, LTRA should be used with caution in individual children. When used, we suggest a therapeutic trial is undertaken, during which efficacy should be carefully monitored. It is likely that children with an apparent EVW phenotype are not a homogeneous group and that subgroups may respond to LTRA treatment depending on the exact patho-physiological mechanisms involved.

Impact of the Ebola epidemic on general and HIV care in Macenta, Forest Guinea, 2014.

The current Ebola epidemic massively affected the Macenta district in Forest Guinea. We aimed at investigating its impact on general and HIV care at the only HIV care facility in the district. Prospective observational single-facility study. Routinely collected data on use of general hospital services and HIV care were linked to Ebola surveillance data published by the Guinea Ministry of Health. In addition, we compared retention among HIV-infected patients enrolled into care in the first semesters of 2013 and 2014. Throughout 2014, service offer was continuous and unaltered at the facility. During the main epidemic period (August-December 2014), compared with the same period of 2013, there were important reductions in attendance at the primary care outpatient clinic (-40%), in HIV tests done (-46%), in new diagnoses of tuberculosis (-53%) and in patients enrolled into HIV care (-47%). There was a smaller reduction in attendance at the HIV follow-up clinic (-11%). Kaplan-Meier estimates of retention were similar among the patients enrolled into care in 2014 and 2013. In a multivariable Cox regression analysis, the year of enrolment was not associated with attrition (hazard ratio 1.02; 95% confidence interval: 0.72-1.43). The Ebola epidemic resulted in an important decrease in utilization of the facility despite unaltered service offer. Effects on care of HIV-positive patients enrolled prior to the epidemic were limited. HIV care in such circumstances is challenging, but not impossible.

Telemedicine in care homes in Airedale, Wharfedale and Craven

Purpose – The purpose of this paper is to observe and analyse the effects of the use of telemedicine in care homes on the use of acute hospital resources. Design/methodology/approach – The study was an uncontrolled retrospective observational review of data on emergency hospital admissions and Emergency Department (ED) visits for care home residents in Airedale, Wharfedale and Craven. Acute hospital activity for residents was observed before and after the installation of telemedicine in 27 care homes. Data from a further 21 care homes that did not use telemedicine were used as a control group, using the median date of telemedicine installation for the “before and after” period. Patient outcomes were not considered. Findings – Care homes with telemedicine showed a 39 per cent reduction in the costs of emergency admissions and a 45 per cent reduction in ED attendances after telemedicine installation. In the control group reductions were 31 and 31 per cent, respectively. The incremental difference in costs between the two groups of care homes was almost £1.2 million. The cost of telemedicine to care commissioners was £177,000, giving a return on investment over a 20-month period of £6.74 per £1 spent. Research limitations/implications – The results should be interpreted carefully. There is inherent bias as telemedicine was deployed in care homes with the highest use of acute hospital resources and there were some methodological limitations due to poor data. Nevertheless, controlling the data as much as possible and adopting a cautious approach to interpretation, it can be concluded that the use of telemedicine in these care homes was cost-effective. Originality/value – There are very few telemedicine studies focused on care homes.

Cold War Command: The Dramatic Story of a Nuclear Submariner

<i>Cold War Command: The Dramatic Story of a Nuclear Submariner</i>

The KTB apatite fission-track profiles: Building on a firm foundation?

Deep boreholes serve as natural laboratories for testing thermochronometers under geological conditions. The Kontinentale Tiefbohrung (KTB) is an interesting candidate because the geological evidence suggests that approximate isothermal holding since the last documented exhumation in the Late Cretaceous to Palaeocene is a reasonable assumption for the thermal histories of the KTB samples. We report 30 new apatite fission-track ages and 50 new mean confined track lengths determined on cores from the 4km deep pilot hole. The ϕ- and ζ-external detector ages are consistent with the population ages from earlier studies and together define a clear age profile. The mean track lengths from this and earlier studies reveal the effects of experimental factors. The measured age and length profiles are compared with the predictions of 24 annealing models for isothermal holding. There are clear discrepancies between the measured and calculated profiles. Down to 1.5km depth, the measured mean track lengths are shorter than the predicted. The balance of methodological evidence indicates that this is due to seasoning, i.e., a shortening of the fossil confined tracks without attendant age reduction. From 2.5 to 4.0km depth, the mean track lengths are longer than the predictions. This suggests that the bias model that weights the probabilities of observing tracks of different length and which is based on experiments relating surface track densities to mean track lengths is not appropriate for confined tracks. Experimental and methodological factors are sometimes difficult to disentangle, but present a sufficient margin for there to be no need to go against the independent geological evidence. Unknown geological events cannot be ruled out but their existence cannot be inferred from the fission-track data alone, much less can the nature or magnitude of such events be specified.

The impact of violence reduction initiatives on emergency department attendance.

Recent violence reduction initiatives in Glasgow have led to a reduction in recorded levels of violent crime.(1) This study evaluates the impact of these initiatives on assault-related emergency department attendances and admissions. A retrospective observational study conducted in Glasgow Royal Infirmary's emergency department comparing assault-related emergency department attendances and hospital admissions over two 30-day study periods (April 2010 and April 2012). The primary outcome measure was the change in assault-related emergency department attendances. The secondary outcome measure was the impact on assault-related hospital and critical care admissions. In April 2010, there were 6098 emergency department attendances, 301 (4.9%) were due to assault. In April 2012, there were 7236 emergency department attendances, 263 (3.6%) were due to assault, representing a significant reduction in assault-related attendances (p < 0.01). There were significant reductions in level 1 admissions 2010 n = 56 (19.2%), 2012 n = 36 (14.0%) p = 0.04 and critical care admissions, 2010 n = 5 (1.7%), 2012 n = 1 (0.4%) p = 0.04. Violence reduction initiatives in Glasgow have contributed to a reduction in assault-related emergency department attendance at Glasgow Royal Infirmary. The reduction in hospital admissions, in particular critical care admissions, suggests a reduction in morbidity and cost to the National Health Service.

Twentieth century dust lows and the weakening of the westerly winds over the Tibetan Plateau

AbstractUnderstanding past atmospheric dust variability is necessary to put modern atmospheric dust into historical context and assess the impacts of dust on the climate. In Asia, meteorological data of atmospheric dust is temporally limited, beginning only in the 1950s. High‐resolution ice cores provide the ideal archive for reconstructing preinstrumental atmospheric dust concentrations. Using a ~500 year (1477–1982 A.D.) annually resolved calcium (Ca) dust proxy from a Tibetan Plateau (TP) ice core, we demonstrate the lowest atmospheric dust concentrations in the past ~500 years during the latter twentieth century. Declines in late nineteenth to twentieth century Ca concentrations significantly correspond with regional zonal wind trends from two reanalysis models, suggesting that the Ca record provides a proxy for the westerlies. Twentieth century warming and attendant atmospheric pressure reductions over northern Asia have potentially reduced temperature/pressure gradients resulting in lower zonal wind velocities and associated dust entrainment/transport in the past ~500 years over the TP.

The Perceived Effect of Duty Hour Restrictions on Learning Opportunities in the Intensive Care Unit.

Many countries have reduced resident duty hours in an effort to promote patient safety and enhance resident quality of life. There are concerns that reducing duty hours may impact residents' learning opportunities. We (1) evaluated residents' perceptions of their current learning opportunities in a context of reduced duty hours, and (2) explored the perceived change in resident learning opportunities after call length was reduced from 24 continuous hours to 16hours. We conducted an anonymous, cross-sectional online survey of 240 first-, second-, and third-year residents rotating through 3 McGill University-affiliated intensive care units (ICUs) in Montreal, Quebec, Canada, between July 1, 2012, and June 30, 2013. The survey investigated residents' perceptions of learning opportunities in both the 24-hour and 16-hour systems. Of 240 residents, 168 (70%) completed the survey. Of these residents, 63 (38%) had been exposed to both 24-hour and 16-hour call schedules. The majority of respondents (83%) reported that didactic teaching sessions held by ICU staff physicians were useful. However, of the residents trained in both approaches to overnight call, 44% reported a reduction in learner attendance at didactic teaching sessions, 48% reported a reduction in attendance at midday hospital rounds, and 40% reported a perceived reduction in self-directed reading after the implementation of the new call schedule. A substantial proportion of residents perceived a reduction in the attendance of instructor-directed and self-directed reading after the implementation of a 16-hour call schedule in the ICU.

Dépistage du cancer du sein dans treize départements français

In France, breast cancer screening programme, free of charge for women aged 50-74 years old, coexists with an opportunistic screening and leads to reduction in attendance in the programme. Here, we reported participation in organized and/or opportunistic screening in thirteen French departments. We analyzed screening data (organized and/or opportunistic) of 622,382 women aged 51-74 years old invited to perform an organized mammography screening session from 2010 to 2011 in the thirteen French departments. The type of mammography screening performed has been reported according to women age, their health insurance scheme, the rurality and the socioeconomic level of their area or residence. We also represented the tertiles of deprivation and participation in mammography screening for each department. A total of 390,831 (62.8%) women performed a mammography screening (organized and/or opportunistic) after the invitation. These women were mainly aged from 55-69 years old, insured by the general insurance scheme and lived in urban, semi-urban or affluent areas. The participation in mammography screening (organized and opportunistic) in France remains below the target rate of 70% expected by health authorities to reduce breast cancer mortality through screening.