United Kingdom Hospitals Research Articles

Pregnancy vitamin D supplementation and offspring bone mineral density in childhood follow-up of a randomized controlled trial

BackgroundFindings from the Maternal Vitamin D Osteoporosis Study (MAVIDOS) trial demonstrated a positive effect of gestational cholecalciferol supplementation on offspring bone mineral density (BMD) at age 4 y. Demonstrating the persistence of this effect is important to understanding whether maternal vitamin D supplementation could be a useful public health strategy to improving bone health. ObjectivesWe investigated whether gestational vitamin D supplementation increases offspring BMD at ages 6–7 y in an exploratory post-hoc analysis of an existing trial. MethodsIn the MAVIDOS randomized controlled trial, pregnant females <14 wk’ gestation with a singleton pregnancy and serum 25-hydroxyvitamin D 25–100nmol/l at 3 United Kingdom hospitals (Southampton, Sheffield, and Oxford) were randomly assigned to either 1000 IU/d cholecalciferol or placebo from 14 to 17-wk gestation until delivery. Offspring born at term to participants recruited in Southampton were invited to the childhood follow-up at ages 4 and 6–7 y. The children had a dual-energy X-ray absorptiometry (DXA, Hologic discovery) scan of whole-body-less-head (WBLH) and lumbar spine, from which bone area, bone mineral content (BMC), BMD, and bone mineral apparent density (BMAD) were derived. Linear regression was used to compare the 2 groups adjusting for age, sex, height, weight, duration of consumption of human milk, and vitamin D use at 6–7 y. ResultsA total of 454 children were followed up at ages 6–7 y, of whom 447 had a usable DXA scan. Gestational cholecalciferol supplementation resulted in higher WBLH BMC [0.15 SD, 95% confidence interval (CI): 0.04, 0.26], BMD (0.18 SD, 95% CI: 0.06, 0.31), BMAD (0.18 SD, 95% CI: 0.04, 0.32), and lean mass (0.09 SD, 95% CI: 0.00, 0.17) compared with placebo. The effect of pregnancy cholecalciferol on bone outcomes was similar at ages 4 and 6–7 y. ConclusionsSupplementation with cholecalciferol 1000 IU/d during pregnancy resulted in greater offspring BMD and lean mass in mid-childhood compared with placebo in this exploratory post-hoc analysis. These findings suggest that pregnancy vitamin D supplementation may be an important population health strategy to improve bone health. Trial registration numberThis trial was registered at the ISRCTN (https://doi.org/10.1186/ISRCTN82927713) as 82927713 and EUDRACT (https://www.clinicaltrialsregister.eu/ctr-search/trial/2007-001716-23/results) as 2007-001716-23.

Recurrent cardiovascular and limb events in 294,428 patients with coronary or peripheral artery disease or ischemic stroke on antiplatelet monotherapy: The RESRISK cohort study

Background and aimsUtilising real-world data, we quantified the burden of cardiovascular risk factors and long-term residual risk of atherothrombotic events among routine care cohorts with coronary (CAD) or peripheral (PAD) artery disease or ischemic stroke (IS) on guideline-recommended antiplatelet monotherapy (APMT). MethodsRetrospective cohort study using data (2010–2020) from the United Kingdom Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics, including adults with CAD, PAD or IS who were first prescribed APMT (CAD/IS: aspirin; PAD: clopidogrel). Primary outcomes (recurrent events): major adverse cardiovascular events (MACE) for CAD/PAD/IS cohorts, major adverse limb events (MALE) for PAD. Results266,478 CAD, 13,162 PAD, and 14,788 IS patients were included (mean age: 71 years; women 37.7%–47.5 %). Risk factor burden was high and attainment of recommended goals was low. There were 73,691, 3,121 and 7,137 MACE among CAD, PAD and IS patients, respectively (median follow-up: 89.9, 42.4 and 75.9 months, respectively), and 4,767 MALE among PAD patients. MACE incidence rate per 1000 person-years was higher in IS (268.7; 95%CI 265.3–272.0) than CAD (92.9; 95%CI 92.5–93.4) or PAD cohorts (97.2; 95%CI 94.6–99.8). MALE incidence rate was 195.9 (95%CI 192.2–199.6) per 1000 person-years. IS patients presented a lower rate of hospitalisations and longer time-to-first hospitalisation, but once hospitalised, they had a longer length-of-stay. PAD patients had the highest hospitalisation rate. ConclusionsAmong a contemporary cohort with cardiovascular disease on APMT, long-term residual atherothrombotic risk remains high despite being on APMT. Greater attention to risk factor control and use of appropriate evidence-based therapy is required to reduce residual risk among this very high-risk population.

Preventing recurrence of endometriosis-related pain by means of long-acting progestogen therapy: the PRE-EMPT RCT.

Endometriosis affects 1 in 10 women, many of whom have surgery for persistent pain. Recurrence of symptoms following an operation is common. Although hormonal treatment can reduce this risk, there is uncertainty about the best option. To evaluate the clinical and cost-effectiveness of long-acting progestogen therapy compared with the combined oral contraceptive pill in preventing recurrence of endometriosis-related pain and quality of life. A multicentre, open, randomised trial with parallel economic evaluation. The final design was informed by a pilot study, qualitative exploration of women's lived experience of endometriosis and a pretrial economic model. Thirty-four United Kingdom hospitals. Women of reproductive age undergoing conservative surgery for endometriosis. Long-acting progestogen reversible contraceptive (either 150 mg depot medroxyprogesterone acetate or 52 mg levonorgestrel-releasing intrauterine system) or combined oral contraceptive pill (30 µg ethinylestradiol, 150 µg levonorgestrel). The primary outcome was the pain domain of the Endometriosis Health Profile-30 questionnaire at 36 months post randomisation. The economic evaluation estimated the cost per quality-adjusted life-years gained. Four hundred and five women were randomised to receive either long-acting reversible contraceptive (N = 205) or combined oral contraceptive pill (N = 200). Pain scores improved in both groups (24 and 23 points on average) compared with preoperative values but there was no difference between the two (adjusted mean difference: -0.8, 95% confidence interval -5.7 to 4.2; p = 0.76). The long-acting reversible contraceptive group underwent fewer surgical procedures or second-line treatments compared with the combined oral contraceptive group (73 vs. 97; hazard ratio 0.67, 95% confidence interval 0.44 to 1.00). The mean adjusted quality-adjusted life-year difference between two arms was 0.043 (95% confidence interval -0.069 to 0.152) in favour of the combined oral contraceptive pill, although this cost an additional £533 (95% confidence interval 52 to 983) per woman. Limitations include the absence of a no-treatment group and the fact that many women changed treatments over the 3 years of follow-up. Use of telephone follow-up to collect primary outcome data in those who failed to return questionnaires resulted in missing data for secondary outcomes. The COVID pandemic may have affected rates of further surgical treatment. At 36 months, women allocated to either intervention had comparable levels of pain, with both groups showing around a 40% improvement from presurgical levels. Although the combined oral contraceptive was cost-effective at a threshold of £20,000 per quality-adjusted life-year, the difference between the two was marginal and lower rates of repeat surgery might make long-acting reversible contraceptives preferable to some women. Future research needs to focus on evaluating newer hormonal preparations, a more holistic approach to symptom suppression and identification of biomarkers to diagnose endometriosis and its recurrence. This trial is registered as ISRCTN97865475. https://doi.org/10.1186/ISRCTN97865475. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 11/114/01) and is published in full in Health Technology Assessment; Vol. 28, No. 55. See the NIHR Funding and Awards website for further award information. The NIHR recognises that people have diverse gender identities, and in this report, the word 'woman' is used to describe patients or individuals whose sex assigned at birth was female, whether they identify as female, male or non-binary.

Home-monitoring for neovascular age-related macular degeneration in older adults within the UK: the MONARCH diagnostic accuracy study.

Most neovascular age-related macular degeneration treatments involve long-term follow-up of disease activity. Home monitoring would reduce the burden on patients and those they depend on for transport, and release clinic appointments for other patients. The study aimed to evaluate three home-monitoring tests for patients to use to detect active neovascular age-related macular degeneration compared with diagnosing active neovascular age-related macular degeneration by hospital follow-up. There were five objectives: Estimate the accuracy of three home-monitoring tests to detect active neovascular age-related macular degeneration. Determine the acceptability of home monitoring to patients and carers and adherence to home monitoring. Explore whether inequalities exist in recruitment, participants' ability to self-test and their adherence to weekly testing during follow-up. Provide pilot data about the accuracy of home monitoring to detect conversion to neovascular age-related macular degeneration in fellow eyes of patients with unilateral neovascular age-related macular degeneration. Describe challenges experienced when implementing home-monitoring tests. Diagnostic test accuracy cohort study, stratified by time since starting treatment. Six United Kingdom Hospital Eye Service macular clinics (Belfast, Liverpool, Moorfields, James Paget, Southampton, Gloucester). Patients with at least one study eye being monitored by hospital follow-up. Detection of active neovascular age-related macular degeneration by an ophthalmologist at hospital follow-up. KeepSight Journal: paper-based near-vision tests presented as word puzzles. MyVisionTrack®: electronic test, viewed on a tablet device. MultiBit: electronic test, viewed on a tablet device. Participants provided test scores weekly. Raw scores between hospital follow-ups were summarised as averages. Two hundred and ninety-seven patients (mean age 74.9 years) took part. At least one hospital follow-up was available for 317 study eyes, including 9 second eyes that became eligible during follow-up, in 261 participants (1549 complete visits). Median testing frequency was three times/month. Estimated areas under receiver operating curves were < 0.6 for all index tests, and only KeepSight Journal summary score was significantly associated with the lesion activity (odds ratio = 3.48, 95% confidence interval 1.09 to 11.13, p = 0.036). Older age and worse deprivation for home address were associated with lower participation (χ2 = 50.5 and 24.3, respectively, p < 0.001) but not ability or adherence to self-testing. Areas under receiver operating curves appeared higher for conversion of fellow eyes to neovascular age-related macular degeneration (0.85 for KeepSight Journal) but were estimated with less precision. Almost half of participants called a study helpline, most often due to inability to test electronically. Pre-specified sample size not met; participants' difficulties using the devices; electronic tests not always available. No index test provided adequate test accuracy to identify lesion diagnosed as active in follow-up clinics. If used to detect conversion, patients would still need to be monitored at hospital. Associations of older age and worse deprivation with study participation highlight the potential for inequities with such interventions. Provision of reliable electronic testing was challenging. Future studies evaluating similar technologies should consider: Independent monitoring with clear stopping rules based on test performance. Deployment of apps on patients' own devices since providing devices did not reduce inequalities in participation and complicated home testing. Alternative methods to summarise multiple scores over the period preceding a follow-up. This trial is registered as ISRCTN79058224. This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/97/02) and is published in full in Health Technology Assessment; Vol. 28, No. 32. See the NIHR Funding and Awards website for further award information.

’Did we do our best?’ Reviewing person-centred compassionate care at the end of life in an acute hospital in the United Kingdom, during the COVID-19 pandemic. An Appreciative Inquiry

ABSTRACT There is an outstanding task for all international healthcare organisations to understand how healthcare services learn from the COVID-19 pandemic. We sought to understand whether the treatment and holistic care received by each person who died with presumed nosocomial COVID-19 in our United Kingdom hospital was provided with kindness and compassion. A multi-professional team carried out a service evaluation underpinned by Appreciative Inquiry (AI) methodology. Our current Learning from Death data collection tool was supplemented by the addition of narrative analysis to augment our qualitative findings. We identified a total of 63/143 patients as dying from presumed nosocomial COVID-19 in our hospital. The deaths occurred in hospital between 15 April 2020 and 29 January 2021. We found evidence of individualised decision-making in complex medical situations, alongside the challenge of managing COVID-19, with appropriate management of deterioration and appropriate symptom control. A Learning from Death programme benefits from a multi-professional approach that utilises the skilled workforce mix that exists in our hospitals. The use of AI methodology and addition of narrative analysis is practical and adds valuable qualitative data to the scrutiny of deaths. Sharing the narrative of those who died during the COVID-19 pandemic has reinforced the evidence that healthcare professionals strive to do their best even in the most challenging circumstances and do so with compassion.

Mitigating machine learning bias between high income and low–middle income countries for enhanced model fairness and generalizability

Collaborative efforts in artificial intelligence (AI) are increasingly common between high-income countries (HICs) and low- to middle-income countries (LMICs). Given the resource limitations often encountered by LMICs, collaboration becomes crucial for pooling resources, expertise, and knowledge. Despite the apparent advantages, ensuring the fairness and equity of these collaborative models is essential, especially considering the distinct differences between LMIC and HIC hospitals. In this study, we show that collaborative AI approaches can lead to divergent performance outcomes across HIC and LMIC settings, particularly in the presence of data imbalances. Through a real-world COVID-19 screening case study, we demonstrate that implementing algorithmic-level bias mitigation methods significantly improves outcome fairness between HIC and LMIC sites while maintaining high diagnostic sensitivity. We compare our results against previous benchmarks, utilizing datasets from four independent United Kingdom Hospitals and one Vietnamese hospital, representing HIC and LMIC settings, respectively.

What Is the Accuracy of Clinical Staging for Stage III-Single-station N2 NSCLC? A Multi-Centre UK Study

IntroductionSingle-station N2 (ssN2) versus multi-station N2 has been used as a selection criterion for treatment recommendations between surgical versus non-surgical multimodality treatment in stage III-N2 NSCLC. We hypothesized that clinical staging would be susceptible to upstaging on pathologic staging and, therefore, challenge this practice. MethodsA retrospective study of prospectively collected routine clinical data for patients with stage III-N2 NSCLC that had completed computed tomography (CT), positron emission tomography (PET), and staging endobronchial ultrasound (EBUS) and had been confirmed clinical stage III-ssN2 at multidisciplinary team discussion and went on to complete surgical resection as the first treatment to provide pathologic staging. The study was completed in two cohorts (A) across a single cancer alliance in England (Greater Manchester) January 1, 2015 to December 31, 2018 and (B) across five United Kingdom centers to validate the findings in part A January 1, 2016 to December 31, 2020. ResultsA total of 115 patients met the inclusion criteria across cohort A (56 patients) and cohort B (59 patients) across 15 United Kingdom hospitals. The proportion of cases in which clinical stage III-ssN2 was upstaged to pathologic stage III-multi-station N2 was 34% (19 of 56) in cohort A, 32% in cohort B (19 of 59), and 33% across the combined study cohort (38 of 115). Most patients had a single radiologically abnormal lymph node on CT and PET (88%, 105 of 115). In the majority, the reasons for missed N2 disease on staging EBUS were due to inaccessible (stations 5, 6, 8, 9) N2 nodes at EBUS (34%, 13 of 38) and accessible lymph nodes not sampled during staging EBUS as not meeting sampling threshold (40%, 15 of 38) rather than false-negative sampling during EBUS (26%, 10 of 38). ConclusionsDuring multidisciplinary team discussions, clinicians must be aware that one-third of patients with stage III-ssN2 on the basis of CT, PET, and staging EBUS do not truly have ssN2 and this questions the use of this criterion to define treatment recommendations.

Full title: “Hopes, worries and expectations” experiences of pregnancy with inflammatory bowel disease: An interpretative phenomenological analysis study

Background and AimsInflammatory Bowel Disease (IBD) affects many women of childbearing age. High levels of voluntary childlessness and high levels of pregnancy-related fears have been reported amongst these patients in several quantitative studies. We investigated the lived experiences of pregnant patients to better understand decision-making processes around family planning. MethodsNine participants between 7 and 34 weeks pregnant (6 Crohn's Disease/3 Ulcerative Colitis), with an age range of 22–39 were recruited prospectively from three United Kingdom hospitals. Semi-structured interviews were conducted, and audio recorded. Interpretative phenomenological analysis was used to interpret the data. ResultsTwo main themes emerged: 1) IBD is perceived as a threat to family planning; and 2) healthcare professional advice, support, and reassurance was important. IBD was viewed as a potential threat to fertility and reproductive health. Consequently, women's lived experience of pregnancy is shaped by anxiety and pregnancy-related worries for mother and baby. Mothers actively sought out expert medical assurances to alleviate some of the perceived fears. ConclusionPrevious research has repeatedly found that women with IBD exhibit high levels of pregnancy-related worries and anxieties. Our findings find that high levels of anxiety are due to patients’ perceptions that IBD is a threat to their reproductive health and their offspring. Women relied on a medicalized discourse to understand their IBD experiences during pregnancy and actively sought biomedical resources for assistance before and during pregnancy. Consultants should be aware that when dealing with pregnant patients, some women may experience anxiety and require extra support.

Accuracy of Toric Intraocular Lens Formulas With Measured Posterior Corneal Astigmatism of Different Orientations

PurposeTo assess whether the use of measured posterior corneal astigmatism (PCA) values improves the prediction accuracy of toric intraocular lens power formulas, compared to predicted PCA values, when the orientation of the steep axis of PCA is non-vertical. DesignRetrospective observational cohort study Methods418 eyes of 344 patients were included in the study. Prediction errors (PE) for postoperative refractive astigmatism at 4 weeks postoperatively were determined using vector analysis and compared for the following toric intraocular lens power formulas: Barrett Toric with predicted posterior corneal astigmatism (PPCA); Barrett Toric with measured posterior corneal astigmatism (MPCA); EVO Toric PPCA; EVO Toric MPCA; Holladay I with Abulafia-Koch regression. Subgroup analysis compared PEs for eyes with a vertically orientated steep axis of PCA (60-120o) to eyes with a non-vertically orientated steep axis of PCA. SettingCathedral Eye Clinic, Belfast, United Kingdom and Tan Tock Seng Hospital, Singapoore. ResultsStandard keratometry was with-the-rule in 48% of eyes, while the steep PCA axis was vertically orientated in 91% of eyes. For all eyes, EVO PPCA had a smaller mean absolute error than Barrett-MPCA, Barrett-PPCA and Abulafia-Koch (p < 0.01 for all). EVO-PPCA had the highest percentage of eyes within 0.50D of predicted postoperative astigmatism for eyes with vertical PCA (61%), while EVO-MPCA had the highest percentage for eyes with non-vertical PCA (54%). EVO-MPCA had the smallest centroid error for all eyes, and the subgroups (p < 0.01 for all). Eyes with non-vertical PCA had a lower percentage within 0.50D than eyes with vertical PCA when using PPCA (43% vs 61%, p = 0.034), but there was no significant difference between these groups when MPCA is used for eyes with non-vertical PCA (54% vs 61%, p = 0.40). ConclusionsWhen the steep axis of posterior corneal astigmatism is not vertically orientated, the use of measured posterior keratometry values improves prediction accuracy.

Impact of electronic AKI alert/care bundle on AKI inpatient outcomes: a retrospective single-center cohort study

Background Outcomes among acute kidney injury (AKI) patients are poor in United Kingdom (UK) hospitals, and electronic alerts and care bundles may improve them. We implemented such a system at West Suffolk Hospital (WSH) called the ‘AKI order set’. We aimed to assess its impact on all-cause mortality, length of stay (LOS) and renal function among AKI patients, and its utilization. Methods Retrospective, single-center cohort study of patients ≥ 18 years old with AKI at WSH, a 430-bed general hospital serving a rural UK population of approximately 280,000. 7243 unique AKI events representing 5728 patients with full data were identified automatically from our electronic health record (EHR) between 02 September 2018 and 1 July 2021 (median age 78 years, 51% male). All-cause mortality, LOS and improvement in AKI stage, demographic and comorbidity data, medications and AKI order set use were automatically collected from the EHR. Results The AKI order set was used in 9.8% of AKI events and was associated with 28% lower odds of all-cause mortality (multivariable odds ratio [OR] 0.72, 95% confidence interval [CI] 0.57–0.91). Median LOS was longer when the AKI order set was utilized than when not (11.8 versus 8.8 days, p < .001), but was independently associated with improvement in the AKI stage (28.9% versus 8.7%, p < .001; univariable OR 4.25, 95% CI 3.53–5.10, multivariable OR 4.27, 95% CI 3.54–5.14). Conclusions AKI order set use led to improvements in all-cause mortality and renal function, but longer LOS, among AKI patients at WSH.

Dedicated services for Barrett’s esophagus—a survey and service assessment of provision in United Kingdom hospitals

Dedicated services for Barrett’s esophagus—a survey and service assessment of provision in United Kingdom hospitals

Hydration and nutrition care practices in stroke: findings from the UK and Australia

BackgroundDehydration and malnutrition are common in hospitalised patients following stroke leading to poor outcomes including increased mortality. Little is known about hydration and nutrition care practices in hospital to avoid dehydration or malnutrition, and how these practices vary in different countries. This study sought to capture how the hydration and nutrition needs of patients’ post-stroke are assessed and managed in the United Kingdom (UK) and Australia (AUS).AimTo examine and compare current in-hospital hydration and nutrition care practice for patients with stroke in the UK and Australia.MethodsA cross-sectional survey was conducted between April and November 2019. Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing post-stroke inpatient acute care or rehabilitation. Non-respondents were contacted up to five times.ResultsWe received 150/174 (86%) completed surveys from hospitals in the UK, and 120/162 (74%) in Australia. Of the 270 responding hospitals, 96% reported undertaking assessment of hydration status during an admission, with nurses most likely to complete assessments (85%). The most common methods of admission assessment were visual assessment of the patient (UK 62%; AUS 58%), weight (UK 52%; AUS 52%), and body mass index (UK 47%; AUS 42%). Almost all (99%) sites reported that nutrition status was assessed at some point during admission, and these were mainly completed by nurses (91%). Use of standardised nutrition screening tools were more common in the UK (91%) than Australia (60%). Similar proportions of hydration management decisions were made by physicians (UK 84%; AUS 83%), and nutrition management decisions by dietitians (UK 98%; AUS 97%).ConclusionDespite broadly similar hydration and nutrition care practices after stroke in the UK and Australia, some variability was identified. Although nutrition assessment was more often informed by structured screening tools, the routine assessment of hydration was generally not. Nurses were responsible for assessment and monitoring, while dietitians and physicians undertook decision-making regarding management. Hydration care could be improved through the development of standardised assessment tools. This study highlights the need for increased implementation and use of evidence-based protocols in stroke hydration and nutrition care to improve patient outcomes.

Tackling a Post-COVID-19 Cholecystectomy Waiting List: Are We Meeting the Challenge?

Background and Objectives: The COVID-19 pandemic has led to a tremendous backlog in elective surgical activity. Our hospital trust adopted an innovative approach to dealing with elective waiting times for cholecystectomy during the recovery phase from COVID-19. This study aimed to evaluate trends in overall cholecystectomy activity and the effect on waiting times. Materials and Methods: A prospective observational study was undertaken, investigating patients who received a cholecystectomy at a large United Kingdom hospital trust between February 2021 and February 2022. There were multiple phased strategies to tackle a 533-patient waiting list: private sector, multiple sites including emergency operating, mobile theatre, and seven-day working. The correlation of determination (R2) and Kruskal-Wallis analysis were used to evaluate trends in waiting times across the study period. Results: A total of 657 patients underwent a cholecystectomy. The median age was 49 years, 602 (91.6%) patients had an ASA of 1-2, and 494 (75.2%) were female. A total of 30 (4.6%) patients were listed due to gallstone pancreatitis, 380 (57.8%) for symptomatic cholelithiasis, and 228 (34.7%) for calculous cholecystitis. Median waiting times were reduced from 428 days (IQR 373-508) to 49 days (IQR 34-96), R2 = 0.654, p < 0.001. For pancreatitis specifically, waiting times had decreased from a median of 218 days (IQR 139-239) to 28 (IQR 24-40), R2 = 0.613, p < 0.001. Conclusions: This study demonstrates the methodology utilised to safely and effectively tackle the cholecystectomy waiting list locally. The approach utilised here has potential to be adapted to other units or similar operation types in order to reduce elective waiting times.

A urological urgent assessment unit service evaluation in a United Kingdom hospital

AbstractWhat are the experiences, evaluations and satisfaction levels of service users requiring ambulatory, urgent and emergency urological care who attended a newly implemented urology assessment unit (UAU) in a National Health Service (NHS) hospital in the United Kingdom (UK)? A UAU within an acute care setting was set up for ambulatory, emergency and urgent urological care. The objectives of the unit was to improve patient satisfaction, divert patients from the emergency department, provide an area for early specialist review, allow earlier discharge from hospital and prevent unnecessary admissions to hospital. The aim of this service evaluation (SE) was to evaluate the service user experience and satisfaction when attending this unit. Surgical assessment units are well‐supported in terms of reducing admissions and diverting patients from emergency departments, however, there is little published research regarding units specifically for urology. Important sources involved in urological care delivery and services advocate their implementation but there remains very little published evidence to support this. Opinion pieces and short case studies have yielded positive results. No research was found that has looked into patient satisfaction, experience and feedback of these units in any detail. A SE was conducted involving sending a postal questionnaire to a random selection of 150 patients who attended the UAU. The questionnaire contained a set of 13 Likert‐style questions with additional free text open‐ended questions for provision of further clarification and service user expression. Questions around age, reason for admission and accessibility to the UAU were also included. The Likert‐style and demographic questions were analysed by quantifying responses to percentages and the open‐ended responses were analysed thematically. The questionnaire response rate of 51% was seen from 76 respondents and these were most commonly over 71 years old (47%). The most common reasons for attending were urinary retention, infection and post‐operative urological problems. Of these, 22% did not need to see a doctor and were treated and discharged by the urology nurse practitioner. The care on the UAU was rated highly and generally found to be preferable over the care provided by emergency departments (ED) and general practitioners (GP) family doctors and patients were grateful to avoid being admitted to hospital. Patients appreciated easy access to specialist care and knowledge. Good levels of communication were highlighted as important. Open‐ended response themes included; nursing, doctors, environment, access, communication, specialist access, preventing ED attendances and hospital admissions. Participants rated the care from the nurses and doctors highly; there was a focus on appreciating seeing a specialist directly and avoiding admission to hospital. They were satisfied with being able to avoid attending their GP or ED, and generally preferred the unit over these routes of care. There are multiple areas within emergency and urgent urological care that require further research.

Understanding the hospital discharge planning process for medical patients with dementia

Background: Poor hospital discharge processes can result in the readmission of patients and potentially increase the stress levels of carers. Therefore, this study sought to understand the factors related to the discharge planning process for patients with dementia. Methods: The researchers interviewed 32 carers of patients with dementia and 20 hospital staff who worked on medical wards in a United Kingdom (UK) hospital. The semi-structured interviews were analysed thematically using a systems theory (patient–carer–staff relationships, hospital equipment and policies). Results: The findings indicated that the following factors could either have a positive or negative impact on discharge planning: patient (e.g. cognitive capacity), carer (e.g. preconceived ideas about care homes), staff (e.g. communication skills), policy (e.g. procedures such as discharge meetings), equipment (e.g. type of service provider delivering the equipment) and the wider social context (e.g. availability of specialist dementia beds in care homes). Conclusion: It is important for hospital staff to adopt a systems perspective and to integrate the different elements of the hospital system when planning for patients’ discharge.

Temporal analysis of non-ST segment elevation-acute coronary syndrome (NSTEACS) outcomes in ‘young’ patients under the age of fifty: A nationwide cohort study

BackgroundThe characteristics and risk factor profile of young patients presenting with non-ST segment elevation acute coronary syndrome (NSTEACS) and how they may have changed over time is not well reported. MethodsWe identified 26,708 NSTEACS patients aged under 50 presenting to United Kingdom (UK) hospitals between 2010 and 2017 from Myocardial Ischaemia National Audit Project (MINAP). We calculated incidence of NSTEACS per 100,000 UK population, using Office of National Statistics (ONS) population estimates, prevalence of comorbidities, ethnicity, and in-hospital mortality. We formed biennial groups to enable comparison, 2010–2011, 2012–2013, 2014–2015 and 2016–2017. ResultsThe incidence of NSTEACS per 100,000 population showed minimal change between 2010 and 2017 (2010: 5.4 per 100,000 and 2017; 4.9 per 100,000). Rates of smoking (2010–11; 58% and 2016–17; 53%), and family history of coronary artery disease (CAD) (2010–11; 51% and 2016–17; 44%) fell, but the proportion of patients from an ethnic minority background (2010–11; 12% and 2016–17; 20%), with diabetes mellitus (DM) (2010–11; 14%, and 2016–17; 18%) and female patients (2010–11; 22% and 2016–17; 24%) increased over the study period. Mortality from NSTEACS remained unchanged (2010–11; 1% and 2016–17; 1%). ConclusionsThe incidence of NSTEACS in patients aged under fifty has not reduced despite reduction in prevalence of risk factors such as smoking hypercholesterolaemia in those admitted to UK hospitals. Despite improved rates of early invasive coronary angiography and percutaneous coronary intervention in ‘young’ NSTEACS patients, in-hospital mortality remains unchanged.

The use of the Hanks Herbst vs Twin-block in Class II malocclusion: A randomized controlled trial

This 2-arm parallel study aimed to compare and evaluate the efficiency of Hanks Herbst (HH) and Twin-block (TB) functional appliances in treating adolescents with Class II malocclusion. A parallel-group randomized controlled trial was undertaken in a single United Kingdom hospital. Eighty participants were recruited and randomized in a 1:1 ratio to receive either the HH or TB appliance. Eligibility criteria included children aged 10-14 years with an overjet of ≥7 mm without dental anomalies. The primary outcome was the time (in months) required to reduce overjet to normal limits (<4 mm). Secondary outcomes included treatment failure rates, complications and their impact on oral health-related quality of life (OHRQOL). Randomization was accomplished using electronic software with allocation concealed using sequentially numbered, opaque, and sealed envelopes. Blinding was only applicable for outcome assessment. Data were analyzed using descriptive statistics and regression analyses to detect between-group differences, including Cox regression for time to treatment success. HH was significantly faster than TB in reducing the overjet to within normal limits (95% confidence interval [CI], -3.00 to -0.03; P= 0.046). Mean overjet reduction was more efficient with the HH than the TB appliance (ß= 1.3; 95% CI, 0.04-2.40; P= 0.04). Fifteen (37.5%) of the participants in the TB group and 7 (17.5%) in the HH group failed to complete the treatment (hazard ratio= 0.54; 95% CI, 0.32-0.91, P= 0.02). However, TB was associated with fewer routine (incidence rate ratio= 0.81; 95% CI, 0.7-0.9; P= 0.004) and emergency (incidence rate ratio= 0.1; 95% CI, 0.1-0.3; P= 0.001) visits. Chairside time was greater with the HH (ß= 2.7; 95% CI, 1.8-3.6, P= 0.001). Participants in both groups experienced complications with similar frequency. A greater deterioration in OHRQOL was found during treatment with the TB. Treatment with HH resulted in more efficient and predictable overjet reduction than TB. More treatment discontinuation and greater deterioration in OHRQOL were observed with the TB. However, HH was associated with more routine and emergency visits. ISRCTN11717011. The protocol was not published before trial commencement. No specific external or internal funding was provided. Treatment for participants was provided as part of routine orthodontic treatment in the hospital.

Tackling antimicrobial resistance: developing and implementing antimicrobial stewardship interventions in four African commonwealth countries through a health partnership model.

In recent years, health partnerships have shared infection prevention and control innovations between United Kingdom hospitals and Low-Middle-Income Countries. However, none had focused on antimicrobial stewardship (AMS), a core component of tackling antimicrobial resistance (AMR). This paper documents an effective approach to developing a program to increase AMS capacity in four African countries: Ghana, Tanzania, Uganda, and Zambia as part of the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) program. A systematic approach was applied to assess gaps in AMS interventions and inform the development of the CwPAMS program through deskbased assessments, including National Action Plans on AMR, online focus group meetings, and expert advisory group reviews. Twelve partnerships were selected for the CwPAMS program. AMS support tools were developed based on recommendations from the scoping, including an AMS checklist tool, a healthcare worker knowledge and attitudes questionnaire, and an antimicrobial prescribing app to support clinical decision-making. Training workshops on AMS were developed and delivered to volunteers in Africa and the UK using a train-the-trainer model. The tools and workshops facilitated capacity building for AMS through the generation and strengthening of knowledge, skills, commitment, structures, systems, and leadership among stakeholders in the UK and Africa. The overall average rating assigned to the program following independent evaluation using the Organisation for Economic Cooperation and Development Assistance Committee Evaluation Criteria was very good. The evaluation also highlighted that the majority of the HPs (75%) focused on AMS and/or improved prescribing practice; all HPs have developed and implemented AMS strategies, guidelines, and tools within their hospitals; and NHS staff were able to translate the knowledge and skills they had received early on in the program into clinical practice in response to COVID-19 challenges.

Development and validation of a hospital frailty risk measure using Canadian clinical administrative data.

Accessible measures specific to the Canadian context are needed to support health system planning for older adults living with frailty. We sought to develop and validate the Canadian Institute for Health Information (CIHI) Hospital Frailty Risk Measure (HFRM). Using CIHI administrative data, we conducted a retrospective cohort study involving patients aged 65 years and older who were discharged from Canadian hospitals from Apr. 1, 2018, to Mar. 31, 2019. We used a 2-phase approach to develop and validate the CIHI HFRM. The first phase, construction of the measure, was based on the deficit accumulation approach (identification of age-related conditions using a 2-year look-back). The second phase involved refinement into 3 formats (continuous risk score, 8 risk groups and binary risk measure), with assessment of their predictive validity for several frailty-related adverse outcomes using data to 2019/20. We assessed convergent validity with the United Kingdom Hospital Frailty Risk Score. The cohort consisted of 788 701 patients. The CIHI HFRM included 36 deficit categories and 595 diagnosis codes that cover morbidity, function, sensory loss, cognition and mood. The median continuous risk score was 0.111 (interquartile range 0.056-0.194, equivalent to 2-7 deficits); 35.1% (n = 277 000) of the cohort were found at risk of frailty (≥ 6 deficits). The CIHI HFRM showed satisfactory predictive validity and reasonable goodness-of-fit. For the continuous risk score format (unit = 0.1), the hazard ratio (HR) for 1-year risk of death was 1.39 (95% confidence interval [CI] 1.38-1.41), with a C-statistic of 0.717 (95% CI 0.715-0.720); the odds ratio for high users of hospital beds was 1.85 (95% CI 1.82-1.88), with a C-statistic of 0.709 (95% CI 0.704-0.714), and the HR of 90-day admission to long-term care was 1.91 (95% CI 1.88-1.93), with a C-statistic of 0.810 (95% CI 0.808-0.813). Compared with the continuous risk score, using a format of 8 risk groups had similar discriminatory ability and the binary risk measure had slightly weaker performance. The CIHI HFRM is a valid tool showing good discriminatory power for several adverse outcomes. The tool can be used by decision-makers and researchers by providing information on hospital-level prevalence of frailty to support system-level capacity planning for Canada's aging population.

The Official Journal of ATTD Advanced Technologies &amp; Treatments for Diabetes Conference 22‐25 February 2023 I Berlin &amp; Online

The Official Journal of ATTD Advanced Technologies &amp; Treatments for Diabetes Conference 22‐25 February 2023 I Berlin &amp; Online