Usual Residence Research Articles

Older people with hip fracture transferred to intermediate care: outcomes in an integrated health and social care model

Following surgery for hip fracture almost a quarter of patients do not return directly to their usual residence, using the resources within intermediate care and enablement. This was a retrospective cohort study involving 156 Salford residents admitted with hip fracture in 2015. Linked health data were collected on those discharged to intermediate care vs home in terms of readmissions, mortality, lengths of stay, delayed transfers of care, diagnoses of delirium and pre-existing forms of dementia. The median duration of the continuous care episode in the intermediate care cohort, inclusive of readmissions to hospital, was 52 days. There was a 26% (n=20) readmission rate from intermediate care. Readmission rates at 120 days were higher among those discharged to intermediate care vs home (OR 3.21, 95% CI 1.37-7.54, p=0.007) and among those with a form of dementia (OR 4.76, 95% CI 1.79-12.63, p=0.0017). Patients with delirium during their acute admission were more likely to be discharged to intermediate care (OR 5.43, 95% CI 2.36-12.47, p=0.0001) and were less likely to ultimately be discharged home (OR 6.40, 95% CI 2.25-18.21, p=0.0005), as were those with some form of dementia (OR 6.60, 95% CI 1.97-22.08, p=0.002). Measurement of the entire care episode demonstrates significant lengths of stay. Medium term readmission rates are higher in those discharged to intermediate care. Delirium and dementia are associated with higher readmission rates and lower rates of discharge to own home. It is imperative that a whole pathway approach to commissioning hip fracture services is established.

Family Patterns In The Context Of International Migration: Evidence From Families Of International Migrants In Lagos, Nigeria

Migration is generally conceived of as the movement of people from one place to another involving change of usual residence. When the movement is from one country to another, it is international migration; when it is within the country, it is referred to as internal migration. The focus of this paper is international migration involving the movements of Nigerians to other countries. Migration tends to create a disruption in social relationships and networks that have existed over the years. It has been theorized that the longer the duration of stay by the migrating member, the more permanent will be the disruption of existing family pattern and relationship. Some studies on international migration in sub-Saharan Africa appear to concentrate more on the issues of “brain-drain” and social differentiation between migrants’ and non-migrants’ households. This paper examine dthe influence of international migration on family patterns. The study’s specific objectives were to investigate the relationship between international migration and the role of migrants in family’s decision-making process; attainment of desired family size; family headship; and childrearing among families of international migrants in Lagos, The study adopted the non-experimental research design. A sample size of six hundred respondents was drawn from six hundred households with families members living outside Nigeria. The study locations were Eti-Osa and Kosofe Local Government Areas in Lagos State. Our findings indicate that there is no relationship between duration of travel of spouses and the number of children born by the respondents. One could speculate that the desired number of children is usually born before the spouses stay away from this country. The absent family members are usually consulted before important family decisions are made because of the former’s financial strength or birth ranking/position compared to the respondents.

Socioeconomic Equity in the Receipt of In-Hospital Care and Outcomes in Australian Acute Coronary Syndrome Patients: The CONCORDANCE Registry

Socioeconomic status (SES) is a social determinant of both health and receipt of health care services, but its impact is under-studied in acute coronary syndrome (ACS). The aim of this study was to examine the influence of SES on in-hospital care, and clinical events for patients presenting with an ACS to public hospitals in Australia. Data from 9064 ACS patient records were collected from 41 public hospitals nationwide from 2009 as part of the Cooperative National Registry of Acute Coronary Syndrome Care (CONCORDANCE) registry. For this analysis, we divided the cohort into four socioeconomic groups (based on postcode of usual residence) and compared the in-hospital care provided and clinical outcomes before and after adjustment for both patient clinical characteristics and hospital clustering. Patients were divided into four SES groups (from the most to the least disadvantaged: 2042 (23%) vs. 2104 (23%) vs. 1994 (22%) vs. 2968 (32%)). Following adjustments for patient characteristics, there were no differences in the odds of receiving coronary angiogram, revascularisation, prescription of recommended medication, or referral to cardiac rehabilitation across the SES groups (p=0.06, 0.69, 0.89 and 0.79, respectively). After adjustment for clinical characteristics, no associations were observed for in-hospital and cumulative death (p=0.62 and p=0.71, respectively). However, the most disadvantaged group were 37% more likely to have a major adverse cardiovascular event (MACE) than the least disadvantaged group (OR (95% CI): 1.37 (1.1, 1.71), p=0.02) driven by incidence of in-hospital heart failure. Although there may be gaps in the delivery of care, this delivery of care does not differ by patient's SES. It is an encouraging affirmation that all patients in Australian public hospitals receive equal in-hospital care, and the likelihood of death is comparable between the SES groups.

A 10-year review of child injury hospitalisations, health outcomes and treatment costs in Australia.

BackgroundChildhood injury is a leading cause of hospitalisation, yet there has been no comprehensive examination of child injury and survival over time in Australia. To examine the characteristics, temporal trend and survival for children who were hospitalised as a result of injury in Australia.MethodA retrospective examination of linked hospitalisation and mortality data for injured children aged 16 years or less during 1 July 2001 to 30 June 2012. Negative binomial regression examined change in injury hospitalisation trends. Cox proportional hazard regression examined the association of risk factors on 30-day survival.ResultsThere were 6 86 409 injury hospitalisations, with an age-standardised rate of 1489 per 1 00 000 population (95% CI 1485.3 to 1492.4) in Australia. Child injury hospitalisation rates did not change over the 10-year period. For every severely injured child, there are at least 13 children hospitalised with minor or moderate injuries. The total cost of child injury hospitalisations was $A2.1 billion (annually $A212 million). Falls (38.4%) were the most common injury mechanism. Factors associated with a higher risk of 30-day mortality were: child was aged ≤10 years, higher injury severity, head injury, injured in a transport incident or following drowning and submersion or other threats to breathing, during self-harm and usual residence was regional/remote Australia.ConclusionsChildhood injury hospitalisation rates have not reduced in 10 years. Children’s patterns of injury change with age, and priorities for injury prevention alter according to developmental stages. The development of a national multisectorial childhood injury monitoring and prevention strategy in Australia is long overdue.

Perfil y evolución de pacientes crónicos complejos en una unidad de subagudos

ObjectiveTo improve the management of geriatric pluripathologic patients in Catalonia, the identification of chronic complex patient (PCC) or patients with advanced chronic disease (MACA) has been promoted. Patients with exacerbated chronic diseases are promoted to be admitted in subacute units (SG) located in intermediate hospitals and specialized in geriatric care, as an alternative to acute hospital. The results of the care process in patients identified as PCC/MACA in SG have not been evaluated. DesignDescriptive-comparative, cross-sectional, and quantitative study. LocationSG located in intermediate care hospital. ParticipantsConsecutive patients admitted in the SG during 6months. Main measurementsWe compared baseline characteristics (demographic, clinical and geriatric assessment data), results at discharge and 30days post-discharge between PCC/MACA patients versus other patients. ResultsOf 244 patients (mean age±SD=85,6±7,5; 65.6%women), 91 (37,3%) were PCC/MACA (PCC=79,1%, MACA=20,9%). These, compared with unidentified patients, had greater comorbidity (Charlson index=3,2±1,8 vs 2,0; p=0,001) and polypharmacy (9,5±3,7 drugs vs 8,1±3,8; p=0,009). At discharge, the return to usual residence and mortality were comparable. PCC/MACA had higher mortality adding the mortality at 30day post-discharge (15,4% vs 8%; p=0,010). In a multi-variable analysis, PCC/MACA identification (p=0,006), as well as a history of dementia (p=0,004), was associated with mortality. Although PCC/MACA patients had higher readmission rate at 30day (18,7% vs 10,5%; p=0,014), in the multivariable analyses, only male, polypharmacy, and heart failure were independently associated to readmission. ConclusionsDespite having more comorbidity and polypharmacy, the outcomes of patients identified as PCC/MACA at discharge of SG, were comparable with other patients, although they experienced more readmissions within 30days, possibly due to comorbidity and polypharmacy.

Long-term Postprocedural Outcomes of Palliative Emergency Stenting vs Stoma in Malignant Large-Bowel Obstruction

Colonic stenting was introduced for palliation of malignant large-bowel obstruction (MLBO) more than 20 years ago but remains controversial. To compare outcomes after palliative stenting vs stoma creation in patients with MLBO requiring emergency management. This observational cohort study assessed 345 patients from New York State with an urgent or emergency admission to the hospital for obstruction secondary to colorectal cancer and who underwent stenting or stoma creation from October 1, 2009, through December 31, 2013. Patients were excluded if they underwent resection within 1 year of the index admission. Palliative stenting vs stoma creation. Primary outcomes included subsequent operation and readmission within 90-day and 1-year follow-up. Secondary outcomes were in-hospital death, major medical and surgical complications, length of stay, total charges, and discharge dispositions. Multivariable hierarchical analyses and propensity score matching were used to compare outcomes between the exposure groups. The cohort included 345 patients (mean [SD] age, 69.9 [14.4] years in the stoma group and 70.9 [16.8] years in the stent group; 87 men [50.3%] in the stoma group and 90 [52.3%] in the stent group; and 114 non-Hispanic white patients [65.9%] in the stoma group and 90 [52.3%] in the stent group). Most patients undergoing stenting were treated at high-volume (104 [60.5%]) vs medium-volume (42 [24.4%]) or low-volume (26 [15.1%]) hospitals (P < .001). Patients undergoing stenting were significantly less likely to experience prolonged length of stay (odds ratio [OR], 0.50; 95% CI, 0.26-0.97; P = .04), more likely to be discharged to their usual residence (OR, 0.14; 95% CI, 0.07-0.28; P < .001), and tended to have similar or fewer complications (major events: OR, 0.81; 95% CI, 0.30-2.18; P = .68; procedural complications: OR, 0.57; 95% CI, 0.11-1.22; P = .10). There was no significant difference between the groups in terms of 90-day and 1-year readmission to the hospitals (90 days: OR, 0.93; 95% CI, 0.49-1.78; P = .83; 1 year: OR, 0.72; 95% CI, 0.38-1.37; P = .30). Subsequent operation at 90 days was also not different between the groups (OR, 1.34; 95% CI, 0.26-6.89; P = .72), but there was a higher chance of subsequent operation at 1 year after the stenting procedure (OR, 2.93; 95% CI, 1.12-7.68; P = .03), with most subsequent operations being restenting. In patients with MLBO and if resection is not part of the treatment plan, stenting is safe and improves the efficiency of care with obvious quality-of-life benefits. It should be offered at experienced centers, and patients should be counseled regarding increased risk of subsequent stenting within 1 year.

The SCHHS hip fracture clinical network experience–Improving care and outcomes through an interprofessional approach

BackgroundHip fractures are a major global health care issue, with the 1.26 million estimated cases in 1990 predicted to increase to 4.5 million by 2050. Varying models of care have been developed to improve outcomes following fragility hip fractures. Most of these care models embrace an interprofessional approach to care. Specialist orthopedic nurses play an important role in the management of fragility hip fracture patients and their contribution to the interprofessional health care team is an important predictor of patient outcomes. Assessment of the problemThe Sunshine Coast Hospital and Health Service (SCHHS) is compromised of four hospitals in South East Queensland, Australia however only one large regional hospital provides specialist hip fracture services. Approximately, 350 older hip fracture patients present to the Sunshine Coast Hospital & Health Service (SCHHS) each year. We used Hospital Health round table (HHRT) data to identify and assess key performance care and management of hip fracture patient and outcomes at SCHHS. The HHRT is a nonprofit membership organisation of health services across Australia and New Zealand that aims to provide opportunity for Health Services to achieve best practice, collect analyse and publish information, identify ways to improve and promote collaboration and networking. Exemplars of best practice are also identified in the data so that organizations can adopt similar models of care. HHRT data identified underperformance in management of hip fracture patients in a number of quality indicators at the study site, including length of stay (LOS), time to surgery and relative stay index (RSI). Strategies for quality improvementFollowing review of HHRT data key stakeholders undertook a quality improvement project and formed the Hip Fracture Clinical Network Group (HFCNG). This was established in 2013 with the aim of improving outcomes and achieving key performance indicators for all elderly patients who sustain a hip fracture through active collaboration and regular communication between a broad group of key clinical stakeholders. Results of the quality improvement projectFollowing the implementation of the initiative the Relative Stay Index reduced from 88% in 2012/13 to 78% in 2014/15, and the average LOS reduced from 10.4 days to 8.6 days. The percentage of patients receiving surgery within 2 days rose from 85% to 96%; demonstrating consistent outperformance of the time to surgery key performance indicator of 80%. The percentage of patients discharged to their place of usual residence increased from 45% to 54%. The rate of complications reduced slightly from 69% to 66%. Rates of hospital acquired anaemia reduced from 20.7% to 15%. Detection of delirium rose over the reporting period from 22% to 34%, enabling rapid management. We noted during this period that there was no corresponding increase in readmission rates for this group of patients. These data reflect improvement to clinical documentation and the appropriate identification of cognitive changes. ConclusionIn this quality improvement report, we describe how key stakeholders were engaged to improve communication and collaboration, and how the use of a national benchmarking dataset enabled health care providers to identify care gaps and inconsistencies in clinical practice. This quality improvement project markedly improved collaboration, clinical practice and patient outcomes.

Life and health satisfaction in the adult population of Iran.

OBJECTIVESIncreasing interest has emerged in the use of subjective well-being as a development indicator and for the evaluation of public policies. The aim of this study was to assess life and health satisfaction and their determinants in the adult population of Iran.METHODSWe conducted a survey of a sample of 3,150 adults at least 18 years of age in Tehran, the capital of Iran. The subjects were selected using a stratified random sampling method, and they were interviewed face-to-face at their usual residence by trained interviewers. Life satisfaction was used as a measure of subjective well-being. We used ordinary least square regression models to assess the associations of life and health satisfaction with socio-demographic variables.RESULTSOn a 0-10 scale, the mean (standard deviation) scores for life and health satisfaction were 6.93 (2.54) and 7.18 (1.97), respectively. The average score for life satisfaction in females was 0.52 points higher than in males. A U-shaped relationship was found between age and life satisfaction, with respondents 35 to 44 years of age having the lowest average level of life satisfaction. Satisfaction with life and health among divorced respondents was significantly lower than among never-married and married participants. The scores for life satisfaction in respondents who rated their health status as poor were 3.83 points lower than in those who rated their health status as excellent.CONCLUSIONSThe majority of the population of Tehran was satisfied with their life and health. Self-rated health status had the greatest impact on life satisfaction.

The Effect of Usual Residency Education on Resident Antibiotic Prescription

The Effect of Usual Residency Education on Resident Antibiotic Prescription

Maternal Deaths Databases Analysis: Ecuador 2003-2013.

Background: Maternal mortality ratio in Ecuador is the only millennium goal on which national agencies are still making strong efforts to reach 2015 target. The purpose of the study was to process national maternal death databases to identify a specific association pattern of variable included in the death certificate.Design and methods: The study processed mortality databases published yearly by the National Census and Statistics Institute (INEC). Data analysed were exclusively maternal deaths. Data corresponds to the 2003-2013 period, accessible through INEC’s website. Comparisons are based on number of deaths and use an ecological approach for geographical coincidences.Results: The study identified variable association into the maternal mortality national databases showing that to die at home or in a different place than a hospital is closely related to women’s socioeconomic characteristics; there was an association with the absence of a public health facility. Also, to die in a different place than the usual residence could mean that women and families are searching for or were referred to a higher level of attention when they face complications.Conclusions: Ecuadorian maternal deaths showed Patterns of inequity in health status, health care provision and health risks. A predominant factor seems unclear to explain the variable association found processing national databases; perhaps every pattern of health systems development played a role in maternal mortality or factors different from those registered by the statistics system may remain hidden. Some random influences might not be even considered in an explanatory model yet.Significance for public healthGeneral agreement on maternal mortality reduction suggests that to reach the millennium target a health system must to be able to provide essential, and emergency obstetric care in a well allocate, geographic, ethnic, and socioeconomic distribution of resources. Patterns of inequity in health status, health care provision, and health risks are demonstrable in Ecuadorian maternal deaths, but at levels below of those three decades ago. However, a predominant factor seems unclear to explain the variable association found processing national databases. It could mean that every pattern of health systems development played a role in maternal mortality, but also that factors different than those registered by the statistics system may remain hidden and that some random influences are not even considered in an explanatory model yet. To use maternal mortality to assess health system development might contribute to a general improvement in system performance.

Comparing alternative statistics on recent fertility trends in Australia

In recent years fertility statistics in the Australian Bureau of Statistics (ABS) publication Births, Australia have suffered from a number of issues, including delayed receipt of registration data from the Registrars and computer processing errors. They prompt questions about the quality of these statistics for measuring the level of fertility and its year-to-year changes. The aim of this paper is to compare three sets of fertility statistics, (1) ABS birth registrations, (2) ABS births by year of occurrence, and (3) births in the Australian Institute of Health and Welfare National Perinatal Data Collection (NPDC), at the national and state/territory scales. Annual births by state/territory of usual residence from the three data sources were obtained for the period 2004–2013 or 2004–2014. Recast Estimated Resident Populations from the ABS were used to calculate Total Fertility Rates. For some states and territories there are non-trivial differences in fertility as recorded by the three data sources. In Queensland the trend in fertility according to ABS birth registrations is quite different from that based on the NPDC; in Tasmania and the Northern Territory birth registrations exceed NPDC births by a notable margin. There appears to be more uncertainty about the levels and annual changes in Australian fertility than many users of the data may realise. All three fertility datasets seem to possess some limitations. It is suggested that a new Australian fertility database be created which employs data linkage to incorporate both birth registrations and perinatal data.

Imported infections: What information should be collected by surveillance systems to inform public health policy?

SummaryBackgroundInternational travel carries the risk of imported diseases, which are an increasingly significant public health problem. There is little guidance about which variables should be collected by surveillance systems for strategy-based surveillance.MethodsSurveillance forms for dengue, malaria, hepatitis A, typhoid and measles were collected from Australia and New Zealand and information on these compared with national surveillance forms from the UK and Canada by travel health experts. Variables were categorised by information relating to recent travel, demographics and disease severity.ResultsTravel-related information most commonly requested included country of travel, vaccination status and travel dates. In Australia, ethnicity information requested related to indigenous status, whilst in New Zealand it could be linked to census categories. Severity of disease information most frequently collected were hospitalisation and death.ConclusionsReviewing the usefulness of variables collected resulted in the recommendation that those included should be: overseas travel, reason for travel, entry and departure dates during the incubation period, vaccination details, traveller's and/or parents' country of birth, country of usual residence, time resident in current country, postcode, hospitalisation and death details. There was no agreement about whether ethnicity details should be collected. The inclusion of these variables on surveillance forms could enable imported infection-related policy to be formulated nationally and internationally.

Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why?

ObjectiveThe present study aims to use a statewide population-based registry to assess the prevalence of low acuity emergency department (ED) presentations, describe the trend in presentation rates and to determine...

Poorer outcomes and greater healthcare costs for hospitalised older people with dementia and delirium: a retrospective cohort study.

To compare healthcare utilisation outcomes among older hospitalised patients with and without cognitive impairment, and to compare the costs associated with these outcomes. Retrospective cohort study of administrative data from a large teaching hospital in Melbourne, Australia from 1 July 2006 to 30 June 2012. People with cognitive impairment were defined as having dementia or delirium coded during the admission. Outcome measures included length of stay, unplanned readmissions within 28 days and costs associated with these outcomes. Regression analysis was used to compare differences between those with and without cognitive impairment. There were 93 300 hospital admissions included in the analysis. 6459 (6.9%) involved cognitively impaired patients. The adjusted median length of stay was significantly higher for the cognitively impaired group compared with the non-cognitively impaired group (7.4 days 6.7-10.0 vs 6.6 days, interquartile range 5.7-8.3; p < 0.001). There were no differences in odds of 28-day readmission. When only those discharged back to their usual residence were included in the analysis, the risk of 28-day readmission was significantly higher for those with cognitive impairment compared with those without. The cost of admissions involving patients with cognitive impairment was 51% higher than the cost of those without cognitive impairment. Hospitalised people with cognitive impairment experience significantly greater length of stay and when discharged to their usual residence are more likely to be readmitted to hospital within 28 days compared with those without cognitive impairment. The costs associated with hospital episodes and 28-day readmissions are significantly higher for those with cognitive impairment. Copyright © 2016 John Wiley & Sons, Ltd.

Patient physiological status at the emergency department-ward interface and emergency calls for clinical deterioration during early hospital admission.

To examine the relationship between physiological status at the emergency department-ward interface and emergency calls (medical emergency team or cardiac arrest team activation) during the first 72hours of hospital admission. Ward adverse events are related to abnormal physiology in emergency department however the relationship between physiology at the emergency department-ward interface and ward adverse events is unknown. Descriptive and exploratory design. The study involved 1980 patients at three hospitals in Melbourne Australia: i) 660 randomly selected adults admitted via the emergency department to medical or surgical wards during 2012 and who had an emergency call; and ii) 1320 adults without emergency calls matched for gender, triage category, usual residence, admitting unit and age. The median age was 78years and 48·8% were males. The median time to the first emergency call was 18·8hours and ≥1 abnormal parameters were documented in 34·9% of patients during the last hour of ED care and 47·1% of patients during first hour of ward care. Emergency calls were significantly more common in patients with heart rate and conscious state abnormalities during the last hour of emergency care and abnormal oxygen saturation, heart rate or respiratory rate during the first hour of ward care. Medical emergency team afferent limb failure occurred in 55·3% patients with medical emergency team activation criteria during first hour of ward care. The use of physiological status at the emergency department-ward interface to guide care planning and reasons for and outcomes of medical emergency team afferent limb failure are important areas for future research.

Evidence for Community Transmission of Community-Associated but Not Health-Care-Associated Methicillin-Resistant Staphylococcus Aureus Strains Linked to Social and Material Deprivation: Spatial Analysis of Cross-sectional Data.

BackgroundIdentifying and tackling the social determinants of infectious diseases has become a public health priority following the recognition that individuals with lower socioeconomic status are disproportionately affected by infectious diseases. In many parts of the world, epidemiologically and genotypically defined community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged to become frequent causes of hospital infection. The aim of this study was to use spatial models with adjustment for area-level hospital attendance to determine the transmission niche of genotypically defined CA- and health-care-associated (HA)-MRSA strains across a diverse region of South East London and to explore a potential link between MRSA carriage and markers of social and material deprivation.Methods and FindingsThis study involved spatial analysis of cross-sectional data linked with all MRSA isolates identified by three National Health Service (NHS) microbiology laboratories between 1 November 2011 and 29 February 2012. The cohort of hospital-based NHS microbiology diagnostic services serves 867,254 usual residents in the Lambeth, Southwark, and Lewisham boroughs in South East London, United Kingdom (UK). Isolates were classified as HA- or CA-MRSA based on whole genome sequencing. All MRSA cases identified over 4 mo within the three-borough catchment area (n = 471) were mapped to small geographies and linked to area-level aggregated socioeconomic and demographic data. Disease mapping and ecological regression models were used to infer the most likely transmission niches for each MRSA genetic classification and to describe the spatial epidemiology of MRSA in relation to social determinants. Specifically, we aimed to identify demographic and socioeconomic population traits that explain cross-area extra variation in HA- and CA-MRSA relative risks following adjustment for hospital attendance data. We explored the potential for associations with the English Indices of Deprivation 2010 (including the Index of Multiple Deprivation and several deprivation domains and subdomains) and the 2011 England and Wales census demographic and socioeconomic indicators (including numbers of households by deprivation dimension) and indicators of population health. Both CA-and HA-MRSA were associated with household deprivation (CA-MRSA relative risk [RR]: 1.72 [1.03–2.94]; HA-MRSA RR: 1.57 [1.06–2.33]), which was correlated with hospital attendance (Pearson correlation coefficient [PCC] = 0.76). HA-MRSA was also associated with poor health (RR: 1.10 [1.01–1.19]) and residence in communal care homes (RR: 1.24 [1.12–1.37]), whereas CA-MRSA was linked with household overcrowding (RR: 1.58 [1.04–2.41]) and wider barriers, which represent a combined score for household overcrowding, low income, and homelessness (RR: 1.76 [1.16–2.70]). CA-MRSA was also associated with recent immigration to the UK (RR: 1.77 [1.19–2.66]). For the area-level variation in RR for CA-MRSA, 28.67% was attributable to the spatial arrangement of target geographies, compared with only 0.09% for HA-MRSA. An advantage to our study is that it provided a representative sample of usual residents receiving care in the catchment areas. A limitation is that relationships apparent in aggregated data analyses cannot be assumed to operate at the individual level.ConclusionsThere was no evidence of community transmission of HA-MRSA strains, implying that HA-MRSA cases identified in the community originate from the hospital reservoir and are maintained by frequent attendance at health care facilities. In contrast, there was a high risk of CA-MRSA in deprived areas linked with overcrowding, homelessness, low income, and recent immigration to the UK, which was not explainable by health care exposure. Furthermore, areas adjacent to these deprived areas were themselves at greater risk of CA-MRSA, indicating community transmission of CA-MRSA. This ongoing community transmission could lead to CA-MRSA becoming the dominant strain types carried by patients admitted to hospital, particularly if successful hospital-based MRSA infection control programmes are maintained. These results suggest that community infection control programmes targeting transmission of CA-MRSA will be required to control MRSA in both the community and hospital. These epidemiological changes will also have implications for effectiveness of risk-factor-based hospital admission MRSA screening programmes.

Dying at home or in the hospital? An observational study in German general practice

ABSTRACTBackground Although determinants of place of death have been investigated in several studies, there is a lack of knowledge on factors associated with dying at home from the general practice perspective.Objectives To identify factors associated with dying at home for patients in German general practice.Methods In a retrospective study, general practitioners of 30 general practices were asked to provide data for all patients aged 18 years or older who died within the last 12 months, using a self-developed questionnaire. ‘Dying in hospital’ was defined as dying in hospital or hospice and ‘dying at home’ as dying at one’s usual residence including the nursing home. Multiple logistic regression analyses were used to determine factors associated with ‘dying at home’; odds ratios (ORs) and their 95% confidence intervals (CI) were calculated as measures of effect size.Results Of 439 deceased patients, 52.2% died at home, and 47.8% died in hospital or hospice. Determinants for dying at home were patients’ care in the last 48 hours of life by family members (OR: 7.8, 95% CI: 3.4–18.0), by general practitioners (GPs) (OR: 7.3, 4.2–12.9) and living in a nursing home (OR: 3.8, 1.7–8.3). In the adjusted model, low comorbidity was positively associated (OR: 3.2, 1.4–7.0), and low functional health status (Karnofsky performance status) was negatively associated with dying at home (OR: 0.3, 0.1–0.7).Conclusion Apart from patient-related factors such as comorbidity and health status, care by family members and GPs respectively, were determinants of dying at home.

The post-Yugoslav space on a demographic crossway: 25 years after the collapse of Yugoslavia

The aim of the article is to integrally assess the demographic changes after 1990. It is presumed that considerable variations exist in terms of intensity of demographic processes. The following analyses encompassed the relevant national or regional statistics, employing methodological adjustment in order to enable data comparison. Herewith, the changing definitions of population presented a special analytical problem. The so-called principle of ?permanent? residence was largely replaced with the principle of ?usual? residence. By way of the usual residence it was possible to single out the present population and thus to approach the analysis. The main goal was to assess the direct and indirect demographic loss within the post-Yugoslav space. The combined analysis showed that the whole post Yugoslav area suffered a loss of about 5 million inhabitants (including the permanent emigration of the former guest-workers). Except from Slovenia, and stagnating Montenegro and Macedonia, all other countries from the Yugoslav space have lost more or less of their population. Losing a quarter of its pre-war population, Bosnia-Herzegovina suffered the most (1.093 million), but the high loss was determined also for the neighboring Serbia and Croatia. Serbia within its pre-war territory lost almost a million or one tenth of its population, while Croatia lost more than half a million or one ninth of its population. The three core Yugoslav areas lost more than 2.5 million. The analyses confirmed the striking regional differences as well. The highest relative depopulation was recorded in Republika Srpska of Bosnia-Herzegovina.

Acute Pyelonephritis with Bacteremia Caused by Enterococcus hirae: A Rare Infection in Humans.

Enterococci are one of the usual residents of the microflora in humans. In the last decade this genus has been reported as the third most common cause of bacteremia. We present the case of a 78-year-old female who was admitted to the emergency room because of nausea, lipothymia, and weakness. She was diagnosed with a pyelonephritis with bacteremia, with the isolation in blood and urine cultures of Escherichia coli and Enterococcus hirae. This last microorganism is a rarely isolated pathogen in humans. Currently it is estimated to represent 1–3% of all enterococcal species isolated in clinical practice.

'High-health, high-performance' horses: risk mitigation strategies for OIE-listed diseases.

The 'high-health, high-performance' (HHP) horse concept has been developed by the World Organisation for Animal Health (OIE) together with the F6ddration Equestre Internationale and the International Federation of Horseracing Authorities. This concept is outlined in the OIE Terrestrial Animal Health Code (Chapter 4.16). It aims to address impediments to the international movement of competition horses through a harmonised, practically feasible, globally applicable framework based on simplified certification requirements for the temporary importation of HHP horses and for their return to their country of usual residence. Based on the principle of compartmentalisation, the high health status of these horses would be established by the application, at all times, of stringent health management practices and biosecurity measures to create and maintain a functional separation between horses within the defined compartment and all other equids. These provisions are intended to mitigate the risk of disease spread for most OIE-listed diseases. For six OIE-listed diseases (African horse sickness, equine influenza, equine infectious anaemia, equine piroplasmosis, glanders and Venezuelan equine encephalomyelitis), the OIE recommends disease-specific mitigation measures, which have been included in a model HHP Veterinary Certificate, to provide additional guarantees to mitigate the risk of disease spread. This article presents the HH P disease risk mitigation strategy. It demonstrates how continuous observance of the HHP biosecurity measures and health management practices provides a scientific rationale for limiting the list of diseases for which HHP horses should be screened with respect to their temporary importation for competition purposes.