Developing the Resident Measure of Safety in Care Homes (RMOS): A Delphi and Think Aloud Study.

OBJECTIVE: This study aimed to develop a measure of contributory factors to safety incidents in care homes to be completed by residents and/or their unpaid carers. INTRODUCTION: Care home residents are particularly vulnerable to patient safety incidents, due to higher likelihood of frailty, multimorbidity and cognitive decline. However, despite residents and their carers wanting to be involved in safety initiatives, there are few mechanisms for them to contribute and make meaningful safety improvements to practice. METHODS: We developed 73 evidence-based items from synthesis and existing measures, which we presented to a panel of stakeholders (residents/carers, health/social care professionals and researchers). We used two online rounds of Delphi to generate consensus (80%) on items important to include in the Resident Measure of Safety in Care Homes (RMOS); a consensus meeting was later held. The draft RMOS developed through the Delphi was presented to participants during 'Think Aloud' interviews using cognitive testing techniques. RESULTS: The 29-item RMOS was developed. Forty-three participants completed Delphi round 1, and 27 participants completed round 2, 11 participants attended the consensus meeting and 12 'Think Aloud' interviews were conducted. Of the 73 original items, 42 items that did not meet consensus in Delphi round 1 were presented in round 2. After the consensus meeting, it was agreed that 35 items would comprise the RMOS questionnaire and were presented in the 'Think Aloud' interviews. Participants suggested numerous changes to items mostly to improve comprehension and ability to answer. CONCLUSION: We have a developed an evidence-based RMOS, with good face validity, to assess contributory factors to safety in care homes from a resident/carer perspective. Future work will involve psychometrically testing the items in a pilot and developing a complementary simplified, dementia-friendly version to promote inclusivity. PATIENT OR PUBLIC INVOLVEMENT: Four patient and public contributors worked with researchers to develop the online questionnaires. Patients (residents) and carers participated on the consensus panel. One member of the research team is an expert by lived experience and was involved in design and analysis decisions. The item list and instructions for the questionnaires were reviewed for face validity, understanding and acceptability by a patient and public involvement group and modified.

Risk factors associated with heel pressure ulcer development in adult population: A systematic literature review.

AIMS: The main aim of this systematic literature review was to identify risk factors for development of heel pressure ulcers and quantify their effect. BACKGROUND: Pressure ulcers remain one of the key patient safety challenges across all health care settings and heels are the second most common site for developing pressure ulcers after the sacrum. DESIGN: Quantitative systematic review. METHODS: Data sources: Electronic databases were searched for studies published between 1809 to March 2020 using keywords, Medical Subject Headings, and other index terms, as well as combinations of these terms and appropriate synonyms. STUDY ELIGIBILITY CRITERIA: Previous systematic literature reviews, cohort, case control and cross-sectional studies investigating risk factors for developing heel pressure ulcers. Only articles published in English were reviewed with no restrictions on date of publication. PARTICIPANTS: patients aged 18 years and above in any care setting. Study selection, data extraction, risk of bias and quality assessment were completed by two independent reviewers. Disagreements were resolved by discussion. RESULTS: Thirteen studies met the eligibility criteria and several potential risk factors were identified. However, eligible studies were mainly moderate to low quality except for three high quality studies. CONCLUSIONS: There is a paucity of high quality evidence to identify risk factors associated with heel pressure ulcer development. Immobility, diabetes, vascular disease, impaired nutrition, perfusion issues, mechanical ventilation, surgery, and Braden subscales were identified as potential risk factors for developing heel pressure ulcers however, further well-designed studies are required to elucidate these factors. Other risk factors may also exist and require further investigation. PROSPERO ID: PROSPERO International prospective register of systematic reviews: CRD42017071459.

Applying a systems thinking lens to injury causation in the outdoors: Evidence collected during 3 years of the Understanding and Preventing Led Outdoor Accidents Data System.

INTRODUCTION: This article presents a detailed systems analysis of injury incidents from 35 Australian led outdoor activity organisations between 2014 to 2017. METHOD: Injury incident reports were collected using a specific led outdoor activity incident reporting system known as UPLOADS (Understanding and Preventing Led Outdoor Accidents Data System). RESULTS: In total, 1367 people sustained injuries from across 20 different activities, with an injury rate of 1.9 injured people per 1000 participants over the three-year period. A total of 2234 contributory factors from multiple levels of the led outdoor activity system were identified from the incident reports, and 361 relationships were identified between contributory factors. DISCUSSION: This systems analysis of injury incidents demonstrates that it is not only factors within the immediate context of the incident (Participants, Environment, Equipment) but factors from across multiple systemic levels that contributes to injury incidents (Schools, Parents, Activity centre management). Prevention efforts should focus on addressing the whole network of contributing factors and not only the prominent factors at the lower system levels within the immediate context of the injury incident occurrences.

Patient safety in marginalised groups: a narrative scoping review.

BACKGROUND: Marginalised groups ('populations outside of mainstream society') experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising. METHODS: Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day. RESULTS: The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors. CONCLUSIONS: This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks. TRIAL REGISTRATION: Not applicable for a scoping review.

Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria.

BACKGROUND: Nigeria still ranks second globally in the number of maternal deaths. Most maternal death reviews in Nigeria are isolated research based reports from a single health facility. This study determined causes and contributory factors of maternal mortality in Ogun statefollowing a periodic State-widematernal and perinatal deaths surveillance and response (MPDSR) review. METHODS: We carried out a retrospective analysis of cases of maternal deaths notified (n = 77) and reviewed (n = 45) in health facilities in Ogun State from 2015 to 2016selected using total sampling method. Using the national MPDSR structured and validated data collection tools or questionnaire, collected data was extracted from existing MPDSR data base, andanalyzed using the Statistical Package for Social Sciences (SPSS) software 20.0. We obtained approval from the State Ministry of Health for this study. RESULTS: Average age at maternal death was 30.8 ± 5.7 years. Haemorrhageand pre-eclampsia or eclampsia account for 43.4 and 36.9% of causes respectively. Leading contributory factors ofmaternal deaths include inadequate human resource for health, delay in seeking care, inadequate equipment, lack of ambulance transportation, and delay in referrals services. 51.1%of the women had antenatal care while a significant proportion of the women were referred from Traditional Births Attendants (TBAs) and mission houses. CONCLUSION: We concluded that many of the contributory factors of maternal mortality could be avoided if preventive measures were taken and adequate care available. MPDSR provides a platform for critical evidence of where the main problems lie, and can provide valuable information on strategies which maternal mortality prevention programs should focus on. The implementation and institutionalization of MPDSR programme is on course in Ogun State. MPDSR is feasible and should be institutionalized in all states of Nigeria. A commitment to act upon the findings of MPDSR is a key prerequisite for success.

Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study.

BACKGROUND: In 25% of affected babies, neonatal encephalopathy results from acute peripartum events, but rigorous review of these cases for quality improvement is seldom reported. New Zealand has maintained a national database of all babies diagnosed with Sarnat moderate and severe neonatal encephalopathy since 2010 under the Perinatal and Maternal Mortality Review Committee. AIMS: To determine the rate of contributory factors, potentially avoidable mortality or morbidity, and to identify key areas for improvements to maternity and neonatal care among cases of neonatal encephalopathy following an acute peripartum event. MATERIALS AND METHODS: Sarnat moderate and severe cases identified from the national collection of neonatal encephalopathy with a history of an acute peripartum event were reviewed using a standardised independent multidisciplinary methodology and a tool for assessing contributory factors and potential avoidability, with the addition of a human factors lens. RESULTS: Forty-seven cases from 2013 to 2015 were reviewed. The most common acute peripartum events were placental abruption (12) and shoulder dystocia (11). Contributory factors were identified in 89%, and the severity of outcome was potentially avoidable in 66%. Key modifiable areas included dynamic risk assessment, preparedness for obstetric and neonatal emergencies, best practice for maternal and fetal surveillance in labour, and documentation. CONCLUSIONS: There is significant potential to improve quality and safety in acute peripartum care to reduce the risk of neonatal encephalopathy. Human factors were not well captured by the clinical notes or review tool. Attention to human factors by improved methodology can enhance review of neonatal encephalopathy.

Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia.

BACKGROUND: The recently published monograph, Neonatal encephalopathy and neurologic outcome, from the American College of Obstetricians and Gynecologists calls for a root cause analysis to identify components of care that contributed to cases of neonatal encephalopathy to design better practices, surveillance mechanisms, and systems. All cases of infants born in New Zealand with moderate and severe neonatal encephalopathy were reported to the New Zealand Perinatal and Maternal Mortality Review Committee from 2010. A national clinical review of these individual cases has not previously been undertaken. OBJECTIVES: The objective of the study was to undertake a multidisciplinary structured review of all cases of neonatal encephalopathy that arose following the onset of labor in the absence of acute peripartum events in 2010-2011 to determine the frequency of contributory factors, the proportion of potentially avoidable morbidity and mortality and to identify themes for quality improvement. STUDY DESIGN: National identification of, and collection of clinical records on, cases of moderate or severe neonatal encephalopathy occurring after the onset of labor in the absence of an acute peripartum event, excluding those with normal gases and Apgar scores at 1 minute, among all cases of moderate and severe neonatal encephalopathy at term in New Zealand in 2010-2011 was undertaken. Cases were included if they had abnormal gases as defined by any of pH of ≤ 7.2, base excess of ≤ -10, or lactate of ≥ 6 or if there were no cord gases, an Apgar score at 1 minute of ≤ 7. A clinical case review was undertaken by a multidisciplinary team using a structured tool to record contributory factors (organization and/or management, personnel, and barriers to access and/or engagement with care), potentially avoidable morbidity and mortality and to identify themes to guide quality improvement. RESULTS: Eighty-three babies fulfilled the inclusion criteria for the review, 56 moderate (67%) and 27 severe (33%), 21 (25%) of whom were deceased prior to hospital discharge. Eighty-four percent of 64 babies with cord gas results had one of pH of ≤ 7.0, base excess of ≤ -12, or lactate of ≥ 6; and 42% (8 of 19) without cord gases had 5 minute Apgar scores < 5. Excluding 5 babies who died within a day of birth, all but 1 baby were admitted to a neonatal unit within 1 day of birth. Contributory factors were identified in 84% of 83 cases, most commonly personnel factors (76%). Fifty-five percent of cases with morbidity or mortality were considered to be potentially avoidable, and 52% of cases were considered potentially avoidable because of personnel factors. The most frequently identified theme related to the use and interpretation of cardiotocography in labor. CONCLUSION: A multidisciplinary case review of neonatal encephalopathy following apparently uncomplicated labor identified a high rate of potentially avoidable morbidity and mortality and issues amenable to quality improvement such as multidisciplinary training of staff in fetal surveillance in labor.

Validation of local review for the identification of contributory factors and potentially avoidable perinatal deaths.

BACKGROUND: Reporting on perinatal mortality commenced 2006 in New Zealand through the Perinatal and Maternal Mortality Review Committee (PMMRC). Following review of international models, a process was developed for use in local review to identify contributory factors and potentially avoidable perinatal deaths. Local review of 720 perinatal deaths in 2009 found contributory factors in 24% of deaths and 14% to be potentially avoidable. AIMS: To validate the process of local review for identification of contributory factors and potentially avoidable perinatal deaths. MATERIAL AND METHODS: Records of 48 perinatal deaths were reviewed by an independent multidisciplinary panel using the same methodology as local review to determine agreement between local and independent review for identification of contributory factors and potentially avoidable perinatal death. RESULTS: Independent review found contributory factors in 54% of deaths compared to 40% by local review. Independent review identified eight deaths and local review identified one death with contributory factors not identified by the other review. Kappa statistic for agreement for identifying contributory factors was substantial [0.63 (0.42, 0.84)]. Independent review found 42% of deaths potentially avoidable compared to 23% by local review. Independent review identified 10 deaths and local review identified one death not identified by the other review. Kappa statistic for agreement for identifying potentially avoidable deaths was moderate [0.50 (0.26, 0.73)]. CONCLUSIONS: This study provides validation of local review for identification of contributory factors in perinatal death. The higher proportion of potentially avoidable perinatal deaths identified by independent review compared to local review requires further exploration.

Contributory factors related to patient safety incidence: A nursing perspective.

Background: There are growing concerns about patient safety and quality assurance enhancement in the healthcare setting because of the increase in the incidence of patient harm and adverse events over the years. Aim: This study explored the contributory factors associated with patient safety practices. Setting: The study was conducted in two private hospitals in Gauteng province, South Africa. Methods: A qualitative approach was used to gain an in-depth understanding of the issues pertaining to patient safety incidence. Purposive sampling was used to select professional nurses practicing within the two private hospitals. Thematic analysis was used. The study utilised the Donabedian model of patient safety and quality. Results: The study revealed that majority of the professional nurses did not understand the concept of patient safety; there was poor communication between the multidisciplinary team. There was poor adherence to patient safety policies. Conclusion: Patient safety issues remain an issue of concern in public health. There is a need for nurses to be capacitated on the implementation of patient safety programmes as well as improving communication within the multidisciplinary team. Identifying and addressing risk and contributory factors will help reduce the global burden of patient harm. Contribution: The study has presented the challenges as seen with patient safety and made recommendations on how to improve patient safety from the nursing perspective. It is anticipated that the results of this study may be used to create awareness on patient safety issues. This should promote a good healthcare climate in private healthcare institutions.

Exploring Differentially Expressed Sperm miRNAs in Idiopathic Recurrent Pregnancy Loss and Their Association with Early Embryonic Development.

The high incidence of idiopathic recurrent pregnancy loss (iRPL) may stem from the limited research on male contributory factors. Many studies suggest that sperm DNA fragmentation and oxidative stress contribute to iRPL, but their roles are still debated. MicroRNAs (miRNAs) are short non-coding RNAs that regulate various biological processes by modulating gene expression. While differential expression of specific miRNAs has been observed in women suffering from recurrent miscarriages, paternal miRNAs remain unexplored. We hypothesize that analyzing sperm miRNAs can provide crucial insights into the pathophysiology of iRPL. Therefore, this study aims to identify dysregulated miRNAs in the spermatozoa of male partners of iRPL patients. Total mRNA was extracted from sperm samples of iRPL and control groups, followed by miRNA library preparation and high-output miRNA sequencing. Subsequently, raw sequence reads were processed for differential expression analysis, target prediction, and bioinformatics analysis. Twelve differentially expressed miRNAs were identified in the iRPL group, with eight miRNAs upregulated (hsa-miR-4454, hsa-miR-142-3p, hsa-miR-145-5p, hsa-miR-1290, hsa-miR-1246, hsa-miR-7977, hsa-miR-449c-5p, and hsa-miR-92b-3p) and four downregulated (hsa-miR-29c-3p, hsa-miR-30b-5p, hsa-miR-519a-2-5p, and hsa-miR-520b-5p). Functional enrichment analysis revealed that gene targets of the upregulated miRNAs are involved in various biological processes closely associated with sperm quality and embryonic development.

Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review.

BACKGROUND: Medication errors are common events that compromise patient safety. Outpatient and ambulatory settings enhance access to healthcare which has been linked to favorable outcomes. While medication errors have been extensively researched in inpatient settings, there is dearth of literature from outpatient settings. AIM: To synthesize the peer-reviewed literature on the prevalence, nature, contributory factors, and interventions to minimize medication errors in outpatient and ambulatory settings. METHOD: A systematic review was conducted using Medline, Embase, CINAHL, and Google Scholar which were searched from 2011 to November 2021. Quality assessment was conducted using the quality assessment checklist for prevalence studies tool. Data related to contributory factors were synthesized according to Reason's accident causation model. RESULTS: Twenty-four articles were included in the review. Medication errors were common in outpatient and ambulatory settings (23-92% of prescribed drugs). Prescribing errors were the most common type of errors reported (up to 91% of the prescribed drugs, high variations in the data), with dosing errors being most prevalent (up to 41% of the prescribed drugs). Latent conditions, largely due to inadequate knowledge, were common contributory factors followed by active failures. The seven studies that discussed interventions were of poor quality and none used a randomized design. CONCLUSION: Medication errors (particularly prescribing errors and dosing errors) in outpatient settings are prevalent, although reported prevalence range is wide. Future research should be informed by behavioral theories and should use high quality designs. These interventions should encompass system-level strategies, multidisciplinary collaborations, effective integration of pharmacists, health information technology, and educational programs.

Injury severity prediction of cyclist crashes using random forests and random parameters logit models.

Cycling provides numerous benefits to individuals and to society but the burden of road traffic injuries and fatalities is disproportionately sustained by cyclists. Without awareness of the contributory factors of cyclist death and injury, the capability to implement context-specific and appropriate measures is severely limited. In this paper, we investigated the effects of the characteristics related to the road, the environment, the vehicle involved, the driver, and the cyclist on severity of crashes involving cyclists analysing 72,363 crashes that occurred in Great Britain in the period 2016-2018. Both a machine learning method, as the Random Forest (RF), and an econometric model, as the Random Parameters Logit Model (RPLM), were implemented. Three different RF algorithms were performed, namely the traditional RF, the Weighted Subspace RF, and the Random Survival Forest. The latter demonstrated superior predictive performances both in terms of F-measure and G-mean. The main result of the Random Survival Forest is the variable importance that provides a ranked list of the predictors associated with the fatal and severe cyclist crashes. For fatal classification, 19 variables showed a normalized importance higher than 5% with the second involved vehicle manoeuvring and the gender of the driver of the second vehicle having the greatest predictive ability. For serious injury classification, 13 variables showed a normalized importance higher than 5% with the bike leaving the carriageway having the greatest normalized importance. Furthermore, each path from the root node to the leaf nodes has been retraced the way back generating 361 if-then rules with fatal crash as consequent and 349 if-then rules with serious injury crash as consequent. The RPLM showed significant unobserved heterogeneity in the data finding four normal distributed indicator variables with random parameters: cyclist age ≥ 75 (fatal prediction), cyclist gender male (fatal and serious prediction), and driver aged 55-64 (serious prediction). The model's McFadden Pseudo R2 is equal to 0.21, indicating a very good fit. Furthermore, to understand the magnitude of the effects and the contribution of each variable to injury severity probabilities the pseudo-elasticity was assessed, gaining valuable insights into the relative importance and influence of the variables. The RF and the RPLM resulted complementary in identifying several roadways, environmental, vehicle, driver, and cyclist-related factors associated with higher crash severity. Based on the identified contributory factors, safety countermeasures useful to develop strategies for making bike a safer and more friendly form of transport were recommended.

Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the National Reporting and Learning System.

INTRODUCTION: Direct oral anticoagulants (DOACs) are considered high risk medicines and are frequently associated with medication errors. The nature of incidents and associated outcomes of such incidents are poorly understood. AREAS COVERED: Using a national patient safety reporting database, the National Reporting and Learning System (NRLS), this study aimed to report the contributory factors and outcomes including severe harm and deaths related to all safety incidents involving DOACs reported in England and Wales between 2017-2019. Reason's accident causation model was used to classify the incidents. EXPERT OPINION: A total of 15,730 incident reports were analyzed. A total of 25 deaths were reported with a further 270 and 55 incidents leading to moderate and severe harm, respectively. A further 8.8% (n = 1381) of incidents were associated with low degree of harm. The majority of the incidents involved active failures (n = 13776; 87.58) including duplication of anticoagulant therapies, patients being discharged without DOACs, non-consideration of renal function, and lack of commencement of DOACs post-surgery suggesting preventability of such reported incidents. This study shows that medication incidents involving DOACs have the potential to cause severe harm and deaths, and there is a need to promote guideline adherence through education, training, and decision support technologies.

Factors Contributing to Rationed Nursing Care in the Slovak Republic-A Secondary Analysis of Quantitative Data.

Rationed nursing care is a significant problem in healthcare facilities worldwide. Awareness of contributing factors to rationed care might support the development and implementation of strategies for reducing this phenomenon from clinical practice. The study examined the association between selected hospital, unit, and staff variables and the prevalence of rationed nursing care. Secondary analysis of cross-sectional data collected between December 2017 and July 2018 from 895 registered nurses in seven acute care hospitals in the Slovak Republic was performed. Data were collected using the questionnaire Perceived Implicit Rationing of Nursing and analyzed by descriptive and inferential statistics in the statistical program SPSS 25.0. Statistically significant associations were found between rationed nursing care and unit type, education, shift type, nurses' experience in the current unit, overtime hours, missed shifts, intention to leave the position, perceived staff adequacy, quality of patient care, and job satisfaction. Differences in rating rationed nursing care, quality of patient care, and job satisfaction were identified based on hospital type. Together with top hospital management, nurse managers should develop targeted interventions focusing on mitigating rationed nursing care from the clinical practice with a focus placed on university hospitals. Quality and safe care might be ensured through constant monitoring of the quality of patient care and job satisfaction of nurses as these factors significantly predicted the estimates of rationed nursing care.

An umbrella review of systematic reviews on contributory factors to medication errors in health-care settings.

INTRODUCTION: Medication errors are common events that compromise patient safety and are prevalent in all health-care settings. This umbrella review aims to systematically evaluate the evidence on contributory factors to medication errors in health-care settings in terms of the nature of these factors, methodologies and theories used to identify and classify them, and the terminologies and definitions used to describe them. AREAS COVERED: Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and Google Scholar were searched from inception to March 2022. The data extraction form was derived from the Joanna Briggs Institute (JBI) Reviewers' Manual, and critical appraisal was conducted using the JBI quality assessment tool. A narrative approach to data synthesis was adopted. EXPERT OPINION: Twenty-seven systematic reviews were included, most of which focused on a specific health-care setting or clinical area. Decision-making mistakes such as non-consideration of patient risk factors most commonly led to error, followed by organizational and environmental factors (e.g. understaffing and distractions). Only 10 studies had a pre-specified methodology to classify contributory factors, among which the use of theory, specifically Reason's theory was commonly used. None of the reviews evaluated the effectiveness of interventions in preventing errors. The collated contributory factors identified in this umbrella review can inform holistic theory-based intervention development.

The characteristics and its contributing factors of refractory rheumatoid arthritis, view of the rheumatologists of China: results of a nationwide cross-sectional survey.

OBJECTIVE: To explore the characteristics of refractory RA and its contributory factors based on the understanding of the rheumatologists of China. METHODS: A national cross-sectional survey was performed in 32 provinces across China, and 1381 rheumatologists were recruited. Information about the sociodemographic background, refractory RA characteristics, and contributory factors was collected using a pre-made questionnaire including fourteen single-choice and four multiple-choice questions, respectively. Each of the single-choice and multiple-choice question had several items. RESULTS: In response to the single-choice questions regarding the definition of refractory RA, 52.28% responded that "the 28 joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR) > 5.1 with presence of signs suggestive of inflammatory disease" is characteristic of refractory RA, whereas 50.18% opined that "If target was not achieved with 2 conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) combined with 1 biological or 1 targeted synthetic DMARD (b/tsDMARD), over a total of 3~6 months" should be considered refractory RA. In addition, 39.32% rheumatologists were in favor of inability to taper glucocorticoids (GCs) ≤ 10mg prednisone or equivalent daily. Additional features considered characteristics of refractory RA were extra-articular manifestations (84.94%), interfering comorbidities (76.32%), and radiographic progression (71.83%). Among the contributory factors, 92.03% considered infection, and interstitial lung disease was chosen by 90.95%, vasculitis by 82.26%, osteoporosis by 70.67%, and fibromyalgia syndrome by 70.38%. CONCLUSIONS: Our survey has demonstrated a variety of concepts of refractory RA among the rheumatologists of China. Disease activity assessment, treatment options, interfering comorbidities, and radiological progression all were associated with the characteristics of refractory RA. Key Points • This study demonstrated the definition, characteristics, and contributing factors of refractory RA from the rheumatologists' views in China. • The clarification of the insights and concepts on refractory RA will help to make comprehensive guidelines to treat this disease, further improving prognosis and reducing the societal burdens of RA.

Self-harm and the COVID-19 pandemic: A study of factors contributing to self-harm during lockdown restrictions.

INTRODUCTION: The COVID-19 pandemic and resulting public health measures may have major impacts on mental health, including on self-harm. We have investigated what factors related to the pandemic influenced hospital presentations following self-harm during lockdown in England. METHOD: Mental health clinicians assessing individuals aged 18 years and over presenting to hospitals in Oxford and Derby following self-harm during the period March 23rd to May 17, 2020 recorded whether the self-harm was related to the impact of COVID-19 and, if so, what specific factors were relevant. These factors were organized into a classification scheme. Information was also collected on patients' demographic characteristics, method of self-harm and suicide intent. RESULTS: Of 228 patients assessed, in 46.9% (N = 107) COVID-19 and lockdown restrictions were identified as influencing self-harm. This applied more to females than males (53.5%, N = 68/127 v 38.6%, N = 39/101, χ2 = 5.03, p = 0.025), but there were no differences in age, methods of self-harm or suicide intent between the two groups. The most frequent COVID-related factors were mental health issues, including new and worsening disorders, and cessation or reduction of services (including absence of face-to-face support), isolation and loneliness, reduced contact with key individuals, disruption to normal routine, and entrapment. Multiple, often inter-connected COVID-related factors were identified in many patients. CONCLUSIONS: COVID-related factors were identified as influences in nearly half of individuals presenting to hospitals following self-harm in the period following introduction of lockdown restrictions. Females were particularly affected. The fact that mental health problems, including issues with delivery of care, predominated has implications for organisation of services during such periods. The contribution of isolation, loneliness and sense of entrapment highlight the need for relatives, friends and neighbours to be encouraged to reach out to others, especially those living alone. The classification of COVID-related factors can be used as an aide-memoire for clinicians.

Single-bicycle crashes: An in-depth analysis of self-reported crashes and estimation of attributable hospital cost.

Cyclists' awareness of their risk of single-bicycle crashes is limited. Thus, knowledge of the most common contributory factors of single-bicycle crashes is required. Similarly, single-bicycle crashes and their costs to society are under-recognized by the public. The aim of this study was to conduct an analysis of single-bicycle crashes occurring in a cohort of cyclists in Denmark and supplement it with estimation of some attributable costs of single-bicycle crashes among all injured cyclists during one year treated in a hospital or emergency room in Denmark. We conducted a one-year follow-up of 6,793 active cyclists (mean age: 45.8 years) encountering 349 single-bicycle crashes (single-bicycle crash rate: 55 per 1,000 person-years). An in-depth analysis of the crashes suggested that daily winter road maintenance is crucial in colder climates and that the current cyclist infrastructure design gives rise to many single-bicycle crashes. Further analysis of the co-occurrence of the factors contributing to the crashes indicated that when the weather is warmer, the factors pertaining to the individual cyclist (and not the road authorities) dominate. The risk of sustaining a more severe injury (i.e. other than light bruises) once in a single-bicycle crash was 18 %. However, for cyclists above 50 years, this risk doubled compared with their younger counterparts, wholly due to a 4.7 times higher risk during the warm season. Among cyclists treated in hospital or emergency room, we estimated the attributable hospital cost of single-bicycle crashes at €1,701 and the attributable cost of municipality care at €417 in the first year after the injury (2019 prices). In cyclists aged 18-60 years and treated in hospital or emergency room, the estimated attributable risk of sickness benefit was 5.2 percentage points in the first year after the injury. We concluded that to increase cyclist safety, the road authorities should improve winter road maintenance and redesign cyclist infrastructure.

Which factors contribute to road crashes in non-commercial and commercial vehicles? An examination of administrative data from motorways in Pakistan.

This study aimed to exhibit the crash distribution and compare the contributory factors (crash characteristics, driver characteristics, vehicle characteristics and road characteristics) responsible for road crashes between non-commercial and commercial vehicles. To achieve the objective, a step-wise binary logistic regression (LR) model was employed with the forward LR method to explore the contributing factors to road crashes between the non-commercial and commercial vehicles. The road crash data (2013-2017) on motorways (M1 and M2) was collected from the National Highway and Motorway Police (NHMP) in Pakistan. During the study period, a total of 1110 road crashes were recorded. The proportion of fatal and non-fatal crashes were 29% and 71% for non-commercial vehicles and 31% and 69% for commercial vehicles, respectively. The results from LR model revealed that drowsy driving, poor road conditions, overspeeding and tire bursting were found to be significant predictors of road crashes. Road crashes caused by drowsy driving and poor vehicle condition were prevalent in commercial vehicles. On the contrary, overspeeding and tire bursting were more prevalent in non-commercial vehicles. The remaining factors could not achieve significant values in the model. On the basis of these empirical findings, suggestions to improve safety were pointed out.

Exploring regional differences in cyclist safety at roundabouts: A comparative study between the UK (based on Northumbria data) and Belgium.

The level of safety for cyclists at roundabouts may vary according to national differences not only in the design itself but also sociodemographic, cyclist and driver behaviour as well as environmental factors. This paper investigates the national influence on cyclist casualty severity at roundabouts by comparing the United Kingdom (using Northumbria as a representative sample) and Belgium. The data included speed limits, socio-demographic characteristics, environmental conditions and driver/cyclist behaviour-related contributory factors. First, a logistic regression analysis for the UK data, including 864 cyclist casualties, was carried out. Increasing the speed limit by ten units (for example 30mph to 40mph) increased the probability of a cyclist being killed or seriously injured by 10%. A cyclist casualty was more than three times more likely to be killed or seriously injured (the odds ratio is 3.02) where sudden braking was recorded as a contributory factor. Second, a separate logistic regression analysis for Belgium was conducted. Cyclists ignoring the priority at roundabouts increased the probability of a fatal or seriously injured collisions (the odds ratio is 2.71). Comparing the individual analysis for both countries, the influence of cyclist age was consistent. Each one-year increase in cyclist age increases chance of being killed or seriously injured as opposed to not being killed or seriously injured by 2 % (odds ratio is 1.02) in both UK and Belgium. A final comparative analysis was applied considering proxy variables for both countries. Three-way chi-square tests of independence showed that all non-behavioural variables (i.e. sociodemographic characteristics, speed limit, and environmental conditions) were found to be statistically different between UK and Belgium for both slight and killed and seriously injured casualties. This suggests that driver/cyclist interaction and behaviour in the two countries is generally similar whilst speed limits, the sociodemographic characteristics of cyclists and environmental conditions are specific for each country. The third part of the logistic regression analysis suggested that the country residual was highly statistically significant. This indicates that there are some statistically significant differences with respect to the characteristics of the two regional datasets used in the analysis.