Methodologies to measure access to care post-discharge in adults with serious injury-related disability: a scoping review.

PURPOSE: This scoping review examined the methodologies used to measure access to care in serious injury-related disability populations, for whom access to care post-discharge has significant implications for patient outcomes and rehabilitation trajectories. METHODS: Four electronic databases were searched for literature published between 1 January 2000 and 15 February 2022. Relevant articles needed to relate to access to care in adult community-dwelling trauma and rehabilitation populations. RESULTS: The initial search identified 679 articles. Following de-duplication, the title/abstract screening was completed on 533 articles, and 56 full-text articles were reviewed. Thirty-eight articles met the eligibility criteria and were included in this review. Of the 38 studies included, there was large heterogeneity in the methodologies used to measure access to care. Two articles used multidimensional measures of access to care. CONCLUSIONS: There is an urgent need to establish the use of multidimensional measures as standard practice in access-to-care research. Failure to account for the multidimensional nature of access to care limits the full realisation of access for people with serious injury-related disability and prevents the implementation of processes that could improve access to health, rehabilitation, and support services and enhance the quality of care for individuals with a serious injury-related disability.

A consistently comprehensive approach to rehabilitation research will provide clearer insight into users' experiences and how to optimise their engagement with services.Multidimensional measures of access to care need to be developed, validated, and used to capture the complexity of access to rehabilitation care and what is important to users.More comprehensive evidence can strengthen consensus on the gold standard of what must be included in the measurement of access to rehabilitation care, to improve service reach and relevance.

Parathyroid hormone changes in infants investigated for inflicted injury; an observational retrospective single centre cohort study.

BACKGROUND: Biochemical and haematological testing is recommended in the United Kingdom when inflicted injury is suspected. We examined the associations of test results with radiologically-confirmed fracture(s), and between test results, in a large retrospective observational cohort. METHODS: Infants up to age two years presenting with suspected inflicted injury, without clinically or radiologically apparent bone disease, and where a skeletal survey was undertaken during the period 1st August 2013 to 31st December 2020, were included. Biochemical parameters: corrected calcium (cCa); phosphate (P); alkaline phosphatase (ALP); parathyroid hormone (PTH); 25-hydroxyvitamin D (25D); and haematological parameters: haemoglobin (Hb); mean corpuscular haemoglobin (MCH); mean corpuscular haemoglobin content (MCHC); mean corpuscular volume (MCV); platelet count were collated together with the results of the radiological assessments. FINDINGS: Of 332 eligible infants (190 male), 142 (84 male) had fracture(s) and/or intracranial injury. Mean PTH in the non-fracture group (n measured 50/190) was 27.3 ng/l; in those with intracranial injury alone (n measured 9/23) was 39.4 ng/l; in those with fracture alone (n measured 62/84) was 45.0 ng/l; and in those with fracture and intracranial injury (n measured 20/35) 51.8 ng/l. F-test of multiple means = 0.0369. There was no difference in 25D between the groups. INTERPRETATION: PTH was raised in infants who had fracture(s), intracranial injury or both. A single raised PTH may not necessarily be an indicator of prior disturbed skeletal health in these circumstances. The relevance of vitamin D status and interpretation of data from biochemical testing should be informed by the overall presentation in suspected inflicted injury cases. A single raised PTH may be a consequence of the child's injuries rather than prior disturbed bone health.

Is urethral microscopy useful in symptomatic male patients without urethral discharge?

National guidelines recommend that male patients presenting with symptoms of urethritis or epididymo-orchitis undergo a urethral swab for microscopy. However, this is resource intensive. The aim of this audit was to determine the proportion of symptomatic patients without urethral discharge who have positive findings on urethral swab microscopy and explore associations between presenting symptoms and microscopy findings. We conducted a retrospective audit of symptomatic male patients who underwent microscopy. There was a significant difference between the percentage of symptomatic patients with positive findings on microscopy in those with and without urethral discharge (67% vs 33%, p < 0.001). In a patient presenting with symptoms other than urethral discharge, the likelihood that positive findings on microscopy would occur in a patient with dysuria was 4.73 times more likely than if they did not have dysuria, when controlling for age, testicular pain or discomfort, and urethral discomfort or penile irritation (p < 0.01). In situations where there are limited resources, patients without urethral discharge presenting with dysuria could be prioritised. However, further research is required to identify and stratify which patients require microscopy.

Relationships between handling, behaviour and stress in lambs at abattoirs.

There is community concern about the treatment of farm animals post-farm gate, particularly animal transport and slaughter. Relationships between lamb behavioural and physiological variables on farm, stockperson, dog and lamb behavioural variables pre-slaughter and plasma cortisol, glucose and lactate in lambs post-slaughter were studied in 400 lambs. The lambs were observed in three behavioural tests, novel arena, flight distance to a human and temperament tests, before transport for slaughter. Closed-circuit television video footage was used to record stockperson, dog and lamb behaviour immediately before slaughter. Blood samples for cortisol, glucose and lactate analyses were collected on farm following the three behavioural tests and immediately post-slaughter. The regression models that best predicted plasma cortisol, glucose and lactate concentrations post-slaughter included a mixture of stockperson and dog behavioural variables as well as lamb variables both on-farm and pre-slaughter. These regression models accounted for 33%, 34% and 44% of the variance in plasma cortisol, glucose and lactate concentrations post-slaughter, respectively. Some of the stockperson and dog behaviours pre-slaughter that were predictive of the stress and metabolic variables post-slaughter included the duration of negative stockperson behaviours such as fast locomotion and lifting/pulling lambs, and the duration of dog behaviours such as lunging and barking at the lamb, while some of the predictive lamb behaviour variables included the durations of jumping and fleeing. Some of the physiological and behavioural responses to the behavioural tests on farm were also predictive of the stress and metabolic variables post-slaughter. These relationships support the well-demonstrated effect of handling on fear and stress responses in livestock, and although not direct evidence of causal relationships, highlight the potential benefits of training stockpeople to reduce fear and stress in sheep at abattoirs.

Low Levels of Branched Chain Amino Acids, Eicosapentaenoic Acid and Micronutrients Are Associated with Low Muscle Mass, Strength and Function in Community-Dwelling Older Adults.

BACKGROUND: Sarcopenia, the age-related decrease in muscle mass and function can result in adverse health outcomes and subsequent loss of independence. Inadequate nutrition is an important contributor to the aetiology of sarcopenia, and dietary strategies are studied to prevent or delay this geriatric syndrome. OBJECTIVE: The present study investigated whether there is an association between biochemical nutrient status markers, muscle parameters and sarcopenia in community-dwelling older adults. DESIGN: Data from the cross-sectional Maastricht Sarcopenia study (MaSS) were used, in which skeletal muscle index (SMI), 4 meter gait speed, 5 times chair stand and handgrip strength were assessed among older adults (n=227). Sarcopenia was defined following the algorithm of the European Working Group on Sarcopenia in Older People. Fasted blood samples were analyses on amino acids levels, RBC phospholipid profile, 25-hydroxyvitamin D (25(OH)D), α-tocopherol, magnesium and homocysteine were determined in fasted blood levels. Generalized linear modelling and logistic regression were used for data analysis. RESULTS: Lower blood levels of essential amino acids (EAA), total branched-chain amino acids (BCAA) and leucine were associated with lower SMI (P<0.001), strength (P<0.001) and longer time to complete the chair stand (P<0.05), whereas no association was found for total amino acids (TAA). Lower levels of eicosapentaenoic acid (EPA), 25(OH)D and homocysteine were associated with lower muscle parameter values (P<0.05). No significant associations were found for SFA, MUFA, PUFA, n-3 and n-6 fatty acids, docosahexaenoic acid (DHA), α-tocopherol-cholesterol ratio and magnesium. Sarcopenia was more frequent among those with lower levels of leucine, BCAA, EAA, EPA, 25(OH)D and higher levels of homocysteine (P<0.05). Age and BMI were identified as relevant covariates. A robust association was only found for lower gait speed and lower 25(OH)D levels. CONCLUSION: Compromised muscle parameters are associated with low blood values of specific amino acids, fatty acids, vitamin D and high homocysteine.

Pre- and undiagnosed-hypertension in urban Chinese adults: a population-based cross-sectional study.

Hypertension is common in adults and often undiagnosed, and the prevalence of pre- and undiagnosed-hypertension remains unclear. We aimed to investigate the prevalence of pre- and undiagnosed-hypertension and their correlates among urban Chinese adults. A total of 7435 participants aged 20-79 were included in this study. Data on demographics, lifestyle and medical history were collected through a structured interview. Pre- and undiagnosed-hypertension was defined as systolic blood pressure/ diastolic blood pressure (SBP/DBP) of 120-139/80-89 mm Hg and SBP⩾140 mm Hg and/or DBP⩾90 mm Hg, respectively, in participants without a history of hypertension and use of antihypertensive medication. Prevalence rates were calculated and standardized using local age- and gender-specific census data. Data were analysed using multinomial logistic regression with adjustment for potential confounders. Of all the participants, 2726 (36.7%) were diagnosed with pre-hypertension and 919 (12.3%) with undiagnosed-hypertension. Undiagnosed-hypertension accounted for 37.3% of all participants with hypertension. The prevalence of pre-hypertension gradually decreased with age, while undiagnosed-hypertension increased, although presenting different changing patterns among men and women. In a fully adjusted multinomial logistic regression, age, male sex, low socio-economic status (SES), abdominal obesity, alcohol drinking, physical inactivity and type 2 diabetes mellitus (T2DM) were significantly associated with increased odds of pre- and undiagnosed-hypertension. In conclusions, the prevalence of pre- and undiagnosed-hypertension was ~50% among urban Chinese adults. Abdominal obesity, low SES, alcohol drinking, physical inactivity and T2DM may be indicators for pre- and undiagnosed-hypertension.

A User and Their Family's Perspective of The Use of a Low-Tech Vs A High-Tech AAC System.

This qualitative case study describes a 9-year-old child, diagnosed with homonymous hemianopia, left side weakness and seizures that has been followed by Access to Communication and Technology Unit in Malta for 5 years. The child previously used a communication book and now uses an iPad as a speech generating device. A semi-structured interview was utilised with the parent to explore preference for each AAC system and the reasons for it. The impact of each AAC system on the family and on the child's communication skills, and perceived barriers in the implementation of the AACs were also explored. The child's own experience using the AAC systems was also investigated using a structured interview format. Talking Mats was used to support the child's understanding of the questions and to explore her perspectives on the two AAC systems using Yes-No responses. The parent interview was analysed thematically and represented visually using a thematic network. This was compared with child responses. Four organising themes emerged including barriers, benefits, facilitators, and expectations. Specific barriers included self-funding in order to provide the child with the best fit high-tech AAC. Perceived benefits for both AAC systems were that it increased her communicative intent. The child's mother perceived access to increased vocabulary and capacity for sentence building, operational autonomy as well as voice output as a benefit of the SGD. The child's results indicated a preference for the high-tech AAC because she found it easier to navigate than the low-tech AAC.

Quality assessment of estrogen receptor and progesterone receptor testing in breast cancer using a tissue microarray-based approach.

Assessing hormone receptor status is an essential part of the breast cancer diagnosis, as this biomarker greatly predicts response to hormonal treatment strategies. As such, hormone receptor testing laboratories are strongly encouraged to participate in external quality control schemes to achieve optimization of their immunohistochemical assays. Nine Dutch pathology departments provided tissue blocks containing invasive breast cancers which were all previously tested for estrogen receptor and/or progesterone receptor expression during routine practice. From these tissue blocks, tissue microarrays were constructed and tested for hormone receptor expression. When a discordant result was found between the local and TMA result, the original testing slide was revised and staining was repeated on a whole-tissue block. Sensitivity and specificity of individual laboratories for testing estrogen receptor expression were high, with an overall sensitivity and specificity [corrected] of 99.7 and 95.4%, respectively. Overall sensitivity and specificity of progesterone receptor testing were 94.8 and 92.6%, respectively. Out of 96 discordant cases, 36 cases would have been concordant if the recommended cut-off value of 1% instead of 10% was followed. Overall sensitivity and specificity of estrogen and progesterone receptor testing were high among participating laboratories. Continued enrollment of laboratories into quality control schemes is essential for achieving and maintaining the highest standard of care for breast cancer patients.

Costs and quality of life in multiple sclerosis patients with spasticity.

BACKGROUND: The resource use and health-related quality of life (HRQoL) of patients with multiple sclerosis (MS) spasticity are not well known. The purpose of this study was to obtain estimates of resource utilization, costs, and HRQoL, for patients with different levels of MS spasticity in southern Sweden. MATERIAL AND METHODS: Cross-sectional data on spasticity severity (using a Numerical Rating Scale, NRS), resource use and HRQoL (using EQ-5D) were collected using a patient questionnaire and chart review. Patients were recruited through a clinic in southern Sweden. The study reviews direct medical, direct non-medical and indirect costs. RESULTS: Total costs were estimated to €114,293 per patient and year. Direct medical costs (€7898) accounted for 7% of total costs. Direct non-medical costs (€68,509) accounted for 60% of total costs. Total costs increased with severity of spasticity: for patients with severe spasticity, the total cost was 2.4 times greater than those for patients with mild spasticity. HRQoL decreased as spasticity increases. CONCLUSION: The results of this study show that MS spasticity is associated with a substantial burden on society in terms of costs and HRQoL.

Budget impact analysis of surgical treatment for obesity in Sweden.

BACKGROUND: The recent substantial increase in the number of obese surgeries performed in Sweden has raised concerns about the budget impact. OBJECTIVE: Our aim in this paper is to present an assessment of the budgetary impact of different policies for surgical intervention for obese and overweight subjects from a healthcare perspective in Sweden. METHODS: The model simulates the annual expected treatment costs of obesity related diseases and surgery in patients of different sex, age and Body Mass Index (BMI). Costs evaluated are costs of surgery plus the excess treatment costs that an obese patient has over and above the treatment costs of a normal-weight patient. The diagnoses that are included for costs assessment are diabetes and cardiovascular disease since these diagnoses are the principal diagnoses associated with obesity. Four different scenarios over the number of surgical operations performed each year are simulated and compared: (1) no surgical operation, (2) 3 000 surgical operations in persons with BMI > 40, (3) 4 000 (BMI > 40), and (4) 5 000 (expanded to BMI > 38). RESULTS: Comparing Scenario 2 with Scenario 1 results in a net budget impact of on average SEK 121 million per annum or SEK 40 000 per patient. This implies that 55 percent of the cost of surgery, set equal to SEK 90 000 for each patient, has been offset by a reduction in the excess treatment costs of obesity related diseases. Expanding annual surgery from 3000 to 4000 the cost-offset increased to 58%. By expanding annual surgery further from 4000 to 5000 and at the same time expanding the indication for surgery from BMI > 40 to BMI > 38, no cost-offset is obtained. CONCLUSION: A cost-minimization strategy for bariatric surgery in Sweden should not expand indication, but rather increase the number of surgeries within the currently accepted indication.

Drug and treatment costs in Parkinson's disease patients in Sweden.

BACKGROUND: Parkinson's disease (PD) is a chronic neurodegenerative disease expected to cause great costs. The aim of this study was to calculate drug and treatment costs in patients with PD in Sweden. METHOD: All healthcare contacts of patients with PD in Stockholm County, Sweden, were extracted from registers together with information on reimbursements from the authorities to the caregivers. PD-related costs were calculated together with non-PD-related costs. Cost per patient was calculated and extrapolated to the whole Swedish population, taking population demographics into consideration. In addition, nationwide PD drug sales statistics were included. RESULTS: The PD prevalence of Stockholm County was estimated to 196 per 100,000 inhabitants, resulting in an estimated total of about 22,000 patients with PD in Sweden. The cost per patient was estimated to SEK 76,000 of which drug costs accounted for SEK 15,880. The annual direct costs in patients with PD in Sweden were SEK 1.7 billion in 2009. CONCLUSION: Our study estimates high direct costs in patients with PD in Sweden, SEK 1.7 billion, 52% for inpatient care, 27% for outpatient care and 21% for drugs. With an ageing population and the medical progress, the financial burden on society will most probably increase in the future. This study might initiate and provide information for discussions about future cost allocations and healthcare priorities.

Reduction of aggression during benzodiazepine withdrawal: effects of flumazenil.

Benzodiazepine withdrawal has been associated with hostile and aggressive behavior. The benzodiazepine antagonist flumazenil has reduced, increased or not affected hostility and aggression in animal and human studies. In the present study we analyzed data collected in a placebo-controlled study of the effects of the benzodiazepine antagonist flumazenil in patients previously treated for benzodiazepine dependency, and healthy controls. The aim was to analyze the effects of flumazenil on hostility and aggression. Ten patients and 10 controls received, on two separate occasions, cumulative doses of flumazenil (0.05, 0.1, 0.25, 0.5 and 1mg at 15min intervals) or placebo. Withdrawal symptoms were rated after each injection. Patients had been free from benzodiazepines for 47 (4-266) weeks on the first occasion. A three-way interaction (groupxtreatmentxdose) was found, and was explained by: 1) patients rating aggression and hostility higher than controls at all times during placebo, while 2) during the flumazenil provocation i) the initial significant difference between patients and controls was no longer significant above the 0.5mg dose, and ii) patients rated aggression and hostility significantly lower above the 0.5mg dose compared to base-line. The results suggest that self-rated aggression and hostility in patients treated for benzodiazepine dependency was reduced by the partial benzodiazepine agonist flumazenil.

Cost-effectiveness analysis of budesonide/formoterol compared with fluticasone in moderate-persistent asthma.

In this economic evaluation, conducted alongside a randomized, double-blind clinical trial, economic data were collected from 339 patients with moderate-persistent asthma randomized to receive twice-daily, double-blind treatment with budesonide/formoterol 160/4.5 microg in a single inhaler (n=166) or fluticasone propionate 250 microg (n=173) for 12 weeks. The mean number of episode-free days (EFD) per patient was significantly greater in the budesonide/formoterol group than the fluticasone group (48.71 compared with 42.34, P=0.0185). Data on medication use, visits to healthcare professionals, and hospitalization were pooled across all six countries and combined with German and Dutch unit cost data to calculate total healthcare costs. Using German unit costs, budesonide/formoterol was associated with significantly lower total healthcare costs per patient over the 12-week period compared with fluticasone (euro 131 compared with euro 210, P=0.0043). Using Dutch unit costs, total healthcare costs were slightly numerically lower in the budesonide/formoterol group than the fluticasone group (euro 102 compared with euro 104), but the difference did not reach statistical significance. Budesonide/formoterol in a single inhaler is more effective than a higher microgram dose of fluticasone alone. It is cost-neutral and may provide cost-savings in some countries.

Correlation of VEGF production with IL1 alpha and IL6 secretion by human pituitary adenoma cells.

OBJECTIVES: Vascular endothelial growth factor (VEGF) is considered to be the most important angiogenic factor involved in the neovascularisation of solid tumours. Regulatory molecules include cytokines and growth factors. Interleukin (IL)1 and IL6 have both been shown to regulate VEGF levels in a variety of tissues. The role of cytokines in the pathogenesis of pituitary tumours remains unclear. We have examined the expression of VEGF and its relationships with IL1 and IL6 in the human pituitary tumour cell line HP75 and a series of human pituitary tumours. We have also looked at the relationship of tumour volume and invasive status to VEGF secretion. METHODS: Surgically resected tumours were routinely cultured in single-cell suspension at 200 K/well (standard unit for culture of dispersed primary pituitary adenoma cells). We measured VEGF, IL1 alpha and IL6 levels by ELISA. Tumour volume and invasion grade were assessed by preoperative magnetic resonance imaging. RESULTS: VEGF was detected in conditioned medium of HP75 cells (900+/-52 pg/ml) and in 82% of tumours tested (range 26-16 464 pg/ml). Tumour volume and secretion of VEGF were significantly associated with levels of IL6 (volume, P = 0.056; VEGF, P < 0.001 (P values based on Spearman's test)) and IL1 alpha produced (volume, P < 0.005; VEGF, P < 0.001). Invasive tumours showed a higher basal secretion of VEGF that that of the non-invasive type; however, this difference was not significant. Addition of exogenous IL1 alpha, but not IL6, significantly increased VEGF production. CONCLUSIONS: The significant associations between VEGF and the levels of IL6 and IL1 alpha suggest an important role for these cytokines in the development of these tumours.

Electrocatalytic proton reduction by dithiolate-bridged diiron carbonyl complexes: a connection to the H-cluster?

Spectroscopic and electrochemical investigation of electrocatalytic proton reduction by Fe(2)(mu-pdt)(CO)(6), 1, have been interpreted in terms of a reaction scheme involving sequential electron-proton reactions to give a two-electron, two-proton product that undergoes rate-limiting dihydrogen elimination. Further reduction, at slightly higher negative potentials, gives a more reactive product and this process dominates reactions conducted at higher acid concentrations. Inhibition of the electrocatalytic reaction by CO is due to the more efficient loss of catalyst and this is best modelled by a reaction that is second order in terms of 1(-). During electrocatalytic proton reduction a new species is observed, which features a bridging CO group and the wavenumbers of the nu(CO) modes of the terminally bound carbonyl groups are similar to those of the carbonyl groups bound to the oxidized form of the H-cluster.

Budesonide/formoterol in a single inhaler (Symbicort) reduces healthcare costs compared with separate inhalers in the treatment of asthma over 12 months.

This open, multinational, randomised, parallel-group, six-month extension conducted in the Swedish centres of a previous six-month study compared the costs of a total of 12 months of treatment with budesonide/formoterol in a single inhaler with budesonide plus formoterol separate inhalers in 320 adults with asthma. Patients received budesonide/formoterol (Symbicort Turbuhaler) 160/4.5 mg delivered doses, two inhalations b.i.d., or corresponding doses of budesonide (Pulmicort Turbuhaler) plus formoterol (Oxis Turbuhaler). Direct costs and indirect costs were estimated. Budesonide/formoterol treatment was associated with reduced healthcare service utilisation and statistically significant reductions in direct (SEK1595, p=0.0004) and total costs (SEK1884, p=0.043) per person per year compared with budesonide plus formoterol. Budesonide/formoterol reduced the average annual emergency room admission cost per person by SEK489.7 (31% of direct cost reduction) and physician costs by SEK235.4 (15%).The direct cost of study, relief and other medication was reduced by SEK893.8 (47% of total reduction). There were no statistically significant differences in efficacy and safety parameters following treatment with budesonide/formoterol from single or separate inhalers, other than a significantly lower proportion of withdrawals with the single inhaler (9.2% vs 19.4%, p=0.008). In summary, budesonide/formoterol treatment from a single inhaler reduced 12-month treatment costs compared with separate inhalers, while maintaining at least as good control of asthma.