Socioeconomic deprivation, age and language are barriers to accessing personal health records: a cross-sectional study of a large hospital-based personal health record system.

OBJECTIVES: To investigate barriers to accessing a hospital-based personal health record (PHR) system. DESIGN: Retrospective cross-sectional study. SETTING: This study was conducted in a large secondary and tertiary acute care trust in Birmingham, UK. PARTICIPANTS: Data were collected from 28 637 patients who attended liver medicine, diabetes, renal medicine or endocrinology specialist outpatient clinics from 1 June 2017 to 31 May 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was sign up to and activation of the PHR. The secondary outcomes were the use of the PHR, defined as the number of logons and frequency of access of specific PHR functions. RESULTS: 8070 patients (28.2%) were signed up to the PHR and 4286 patients (53.1% of those signed up) went on to activate their PHR account. Patients aged 75 years and older were significantly less likely to be signed up (adjusted OR, aOR 0.40, 95% CI 0.36 to 0.44) or to activate (aOR 0.39, 0.32 to 0.47) their PHR than patients aged 35-54. Patients who did not need an interpreter were more likely to be signed up (aOR 1.63, 95% CI 1.33 to 1.99) and to activate (aOR 3.16, 95% CI 1.96 to 5.09) their PHR. Patients living in the least deprived areas were more than twice as likely to be signed up (aOR 2.31, 95% CI 2.04 to 2.63), and were three times more likely to activate their PHR (aOR 2.99, 95% CI 2.40 to 3.71), than those in the most deprived. CONCLUSION: Socioeconomic deprivation, older age and non-English language were significant barriers to accessing a hospital-based PHR. Strategies are needed to account for these factors to ensure that PHRs do not widen health inequalities.

A Field-Deployable and Low-Cost PCR (FLC-PCR) Thermocycler for the Rapid Detection of Environmental E. coli.

This is a proof-of-concept study for the development of a field-deployable and low-cost PCR thermocycler (FLC-PCR) to perform Polymerase Chain Reaction (PCR) for the rapid detection of environmental E. coli. Four efficient (77.1 W) peltier modules are used as the central temperature control unit. One 250 W silicone heating pad is used for the heating lid. The PID (proportional-integral-derivative) control algorithm for the thermocycles is implemented by a low-cost 8-bit, 16 MHz microcontroller (ATMEGA328P-PU). ybbW and uidA genes from specific E. coli colonies were used as amplicons for the PCR reactions that were carried out by a commercial PCR machine (Bio-Rad) and our FLC-PCR thermocycler. The heating and cooling speeds averaged 1.11 ± 0.33°C/s which is on a par with the commercial bench-top PCR thermocycler and the efficiency of the heating lid outperformed the Bio-Rad PCR thermocycler. The overall cost of the system is lower than $200 which is more than ten times lower than commercially available units. The heating block can be customized to accommodate different PCR tubes and even microfluidic chambers. An 8000 W portable power generator will be used as the power supply for field studies.

Unacceptable failures: the final report of the Lancet Commission into liver disease in the UK.

This final report of the Lancet Commission into liver disease in the UK stresses the continuing increase in burden of liver disease from excess alcohol consumption and obesity, with high levels of hospital admissions which are worsening in deprived areas. Only with comprehensive food and alcohol strategies based on fiscal and regulatory measures (including a minimum unit price for alcohol, the alcohol duty escalator, and an extension of the sugar levy on food content) can the disease burden be curtailed. Following introduction of minimum unit pricing in Scotland, alcohol sales fell by 3%, with the greatest effect on heavy drinkers of low-cost alcohol products. We also discuss the major contribution of obesity and alcohol to the ten most common cancers as well as measures outlined by the departing Chief Medical Officer to combat rising levels of obesity-the highest of any country in the west. Mortality of severely ill patients with liver disease in district general hospitals is unacceptably high, indicating the need to develop a masterplan for improving hospital care. We propose a plan based around specialist hospital centres that are linked to district general hospitals by operational delivery networks. This plan has received strong backing from the British Association for Study of the Liver and British Society of Gastroenterology, but is held up at NHS England. The value of so-called day-case care bundles to reduce high hospital readmission rates with greater care in the community is described, along with examples of locally derived schemes for the early detection of disease and, in particular, schemes to allow general practitioners to refer patients directly for elastography assessment. New funding arrangements for general practitioners will be required if these proposals are to be taken up more widely around the country. Understanding of the harm to health from lifestyle causes among the general population is low, with a poor knowledge of alcohol consumption and dietary guidelines. The Lancet Commission has serious doubts about whether the initiatives described in the Prevention Green Paper, with the onus placed on the individual based on the use of information technology and the latest in behavioural science, will be effective. We call for greater coordination between official and non-official bodies that have highlighted the unacceptable disease burden from liver disease in England in order to present a single, strong voice to the higher echelons of government.

Proximity to transplant center and outcome among liver transplant patients.

In the United States, distance from liver transplant center correlates with worsened outcomes; the effects of geography elsewhere are unassessed. We performed a national registry analysis of United Kingdom listings for liver transplantation (1995-2014) and assessed whether travel time to transplant center correlates with outcome. There were 11 188 listings assessed (8490 transplanted), with a median travel time to center of 60 minutes (range 36-86). Of the national population, 3.38 × 107 (55.1%) reside ≥60 minutes from a center, and 7.65 × 106 (12.5%) >119 minutes. After competing risk analysis, increasing travel time was associated with an increased risk of death after listing (subdistribution hazard ratios relative to <60 minutes of 1.33 for 60-119 and 1.27 for >119 minutes; P < 0.001) and reduced likelihood of transplantation or recovery (0.94 and 0.86; P < 0.001). Among those transplanted, travel time was not associated with retransplant-free survival (P = 0.532). We used our model to examine optimal placement of a new center and identify a single site with a total travel time reduction of ≈10%. Our findings of disparities in accessibility of liver transplantation showed worse outcomes following listing in those distant from their transplant center, and our description of a method to model a new center complement existing data and support similar analyses of other networks.

Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK.

This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities. We continue to press for reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place, and the introduction of minimum unit pricing in England, targeted at the heaviest drinkers. Results from the introduction of minimum unit pricing in Scotland, with results from Wales to follow, are likely to seriously expose the weakness of England's position. The increasing prevalence of obesity-related liver disease, the rising number of people diagnosed with type 2 diabetes and its complications, and increasing number of cases of end-stage liver disease and primary liver cancers from non-alcoholic fatty liver disease make apparent the need for an obesity strategy for adults. We also discuss the important effects of obesity and alcohol on disease progression, and the increased risk of the ten most common cancers (including breast and colon cancers). A new in-depth analysis of the UK National Health Service (NHS) and total societal costs shows the extraordinarily large expenditures that could be saved or redeployed elsewhere in the NHS. Excellent results have been reported for new antiviral drugs for hepatitis C virus infection, making elimination of chronic infection a real possibility ahead of the WHO 2030 target. However, the extent of unidentified cases remains a problem, and will also apply when new curative drugs for hepatitis B virus become available. We also describe efforts to improve standards of hospital care for liver disease with better understanding of current service deficiencies and a new accreditation process for hospitals providing liver services. New commissioning arrangements for primary and community care represent progress, in terms of effective screening of high-risk subjects and the early detection of liver disease.

Controversies surrounding authorship of manuscripts by industry employees: academic and industry perspectives.

The medical device and pharmaceutical industries play an essential role in the development of cardiovascular devices and drugs, and industry employees are frequently listed as co-authors of clinical trials published in peer-reviewed journals. Potential conflicts of interest in biomedical research have attracted significant attention in recent years, but issues and challenges surrounding authors who are industry employees have not received nearly as much scrutiny. We present a comprehensive discussion of the concerns and challenges regarding the role of industry in the authorship of scientific manuscripts. Academic co-authors, industry employees, the editors of medical journals, and, most importantly, readers, need to consider the perception and implications that accompany industry employee authorship. Potential concerns include the effect of industry authors (and industry support) on study design, data analysis, interpretations, conclusions, and, ultimately, scientific content. Meaningful contributions from industry employees must be acknowledged and reported in scientific and clinical publications. Efforts to provide full transparency on industry support and the role of industry contributors are necessary to maintain confidence in the reports of studies with industry involvement.

Tele-pharmacy in rural Scotland: a proof of concept study.

INTRODUCTION: Technology enables medical services to be provided to rural communities. This proof of concept study assessed the feasibility and acceptability of delivering community pharmacy services (CPS; including advice, sale of over-the-counter products and dispensing of prescriptions) by tele-technology (the Telepharmacy Robotic Supply Service (TPRSS)) to a rural population in Scotland. METHODS: Data collection included the following: postal surveys to local residents; focus groups/ interviews with pharmacists, other healthcare professionals (HCPs) and service users, at baseline and follow-up; TPRSS logs. Interviews/focus groups were audio-recorded, transcribed and thematically analysed. Descriptive statistics were reported for survey data. RESULTS: Qualitative results: Pre-installation: residents expressed satisfaction with current pharmacy access. HCPs believed the TPRSS would improve pharmacy access and reduce pressure on GPs. Concerns included costs, confidentiality, patient safety and 'fear' of technology. Post-installation: residents and pharmacy staff were positive, finding the service easy to use. Quantitative results: Pre-installation: almost half the respondents received regular prescription medicines and a third used an over-the-counter (OTC) medicine at least monthly. More than 80% (124/156) reported they would use the TPRSS. There was low awareness of the minor ailment service (MAS; 38%; 59/156). Post-installation: prescription ordering and OTC medicine purchase were used most frequently; the video link was used infrequently. Reasons for non-use were lack of need (36%; 40/112) and linkage to only one pharmacy (31%; 35/112). DISCUSSION: Community pharmacy services delivered remotely using tele-technology are feasible and acceptable. A larger study should be undertaken to confirm the potential of the TPRSS to reduce health inequalities in rural areas.

Metagenomic assessment of the functional potential of the rumen microbiome in Holstein dairy cows.

The microbial ecology of the rumen microbiome is influenced by the diet and the physiological status of the dairy cow and can have tremendous influence on the yield and components of milk. There are significant differences in milk yields between first and subsequent lactations of dairy cows, but information on how the rumen microbiome changes as the dairy cow gets older has received little attention. We characterized the rumen microbiome of the dairy cow for phylogeny and functional pathways by lactation group and stage of lactation using a metagenomics approach. Our findings revealed that the rumen microbiome was dominated by Bacteroidetes (70%), Firmicutes (15-20%) and Proteobacteria (7%). The abundance of Firmicutes and Proteobacteria were independently influenced by diet and lactation. Bacteroidetes contributed to a majority of the metabolic functions in first lactation dairy cows while the contribution from Firmicutes and Proteobacteria increased incrementally in second and third lactation dairy cows. We found that nearly 70% of the CAZymes were oligosaccharide breaking enzymes which reflect the higher starch and fermentable sugars in the diet. The results of this study suggest that the rumen microbiome continues to evolve as the dairy cow advances in lactations and these changes may have a significant role in milk production.

Estimating the burden of minor ailment consultations in general practices and emergency departments through retrospective review of routine data in North East Scotland.

BACKGROUND: Minor ailment attendances in general practices and emergency departments (EDs) place significant burden on health care resources. OBJECTIVES: To estimate the prevalence and type of minor ailment consultations for adults in general practice and ED that could be managed in a community pharmacy. METHODS: Retrospective review of routine data from general practices (n = 2) and one ED in North East Scotland. Two independent consensus panels assessed each consultation summary to determine whether it represented a minor ailment. Outcomes included prevalence of consultations for minor ailments in general practice and ED and frequency of different minor ailment type that could be managed in community pharmacies. RESULTS: In total, of the 494 general practice and 550 ED consultations assessed, 13.2% [95% confidence interval (CI): 18.6-25.9%] and 5.3% (95% CI: 4.0-8.0%), respectively, were categorized as minor ailments suitable for management in community pharmacies. Consensus among panel members was moderate for general practice consultations, but fair to poor for ED consultations. Agreement between uni- and multi-disciplinary panels was good. Applied to national data, these estimates would equate to ~18 million general practice and 6500000 ED consultations that could be redirected to community pharmacy, equating to ~£1.1 billion in resources. CONCLUSION: Minor ailment consultations still present a major burden on higher cost settings. Effective strategies are needed to raise awareness among patients and health professionals regarding conditions that can be managed effectively in pharmacies and to change patient health-seeking behaviour for such conditions.

How to set up a low cost tele-ultrasound capable videoconferencing system with wide applicability.

BACKGROUND: Worldwide ultrasound equipment accessibility is at an all-time high, as technology improves and costs decrease. Ensuring that patients benefit from more accurate resuscitation and diagnoses from a user-dependent technology, such as ultrasound, requires accurate examination, typically entailing significant training. Remote tele-mentored ultrasound (RTUS) examination is, however, a technique pioneered in space medicine that has increased applicability on earth. We, thus, sought to create and demonstrate a cost-minimal approach and system with potentially global applicability. METHODS: The cost-minimal RTUS system was constructed by utilizing a standard off-the-shelf laptop computer that connected to the internet through an internal wireless receiver and/or was tethered through a smartphone. A number of portable hand-held ultrasound devices were digitally streamed into the laptop utilizing a video converter. Both the ultrasound video and the output of a head-mounted video camera were transmitted over freely available Voice Over Internet Protocol (VOIP) software to remote experts who could receive and communicate using any mobile device (computer, tablet, or smartphone) that could access secure VOIP transmissions from the internet. RESULTS: The RTUS system allowed real-time mentored tele-ultrasound to be conducted from a variety of settings that were inside buildings, outside on mountainsides, and even within aircraft in flight all unified by the simple capability of receiving and transmitting VOIP transmissions. . Numerous types of ultrasound examinations were conducted such as abdominal and thoracic examinations with a variety of users mentored who had previous skills ranging from none to expert. Internet connectivity was rarely a limiting factor, with competing logistical and scheduling demands of the participants predominating. CONCLUSIONS: RTUS examinations can educate and guide point of care clinical providers to enhance their use of ultrasound. The scope of the examinations conducted is limited only by the time available and the criticality of the subject being examined. As internet connectivity will only improve worldwide, future developments need to focus on the human factors to optimize tele-sonographic interactions.

Cost analysis of robot-assisted laparoscopic versus hand-assisted laparoscopic partial nephrectomy.

PURPOSE: To perform a cost comparison of three approaches to partial nephrectomy (PN): Open (OPN), hand-assisted laparoscopic (HALPN), and robot-assisted (RAPN). PATIENTS AND METHODS: We retrospectively evaluated cost and clinical data from patients undergoing OPN, HALPN, and RAPN from 2007 to 2010 (n=89). Baseline demographic data, patient comorbidities, R.E.N.A.L. nephrometry score, and perioperative outcomes were assessed. Costs and subcosts from the operating room (OR) and hospital were evaluated using nonparametric statistical analyses. RESULTS: Patient demographics and tumor characteristics were similar between HALPN and RAPN, while OPN patients had more comorbidities and more difficult-to-resect tumors. Thus, HALPN and RAPN were directly compared, while OPNs were excluded from the analysis. No difference was found in overall costs between HALPN and RAPN ($13,560 vs $13,439, P=0.29). OR costs were higher for RAPN ($7276 vs $5708, P=0.0001) because of the higher robotic capital and reusable equipment costs that outweighed higher disposable costs in the HALPN group. OR time-related costs were similar between groups. RAPN patients had a shorter length of stay (LOS), which decreased postoperative hospital costs ($4371 vs $5984, P=0.002). CONCLUSIONS: No difference in overall cost was found between RAPN and HALPN. Robot allocation, OR equipment use, and LOS are important determinants of total cost. Further study regarding recovery and quality of life may reveal added benefits to minimally invasive approaches and increase use of nephron-sparing surgery.

Animal production systems of small farms in the Kaski district of Nepal.

The aim of this study was to describe animal production on small farms in the Kaski district of Nepal, with the goal of identifying areas where animal health and productivity could be improved. Eighty-five randomly selected farms from four different Village Development Committees were visited. Farmers were interviewed and premises and animals visually inspected on all farms. Feed samples were collected from a subset of farms. The most commonly kept species were water buffalo (used for milk and meat), cattle (used for milk and labor), and goats (used for meat). Average milk production levels were 4.7 kg/day for water buffalo and 1.9 kg/day for cattle. All animals were milked manually, no calves were weaned, and only one farm practiced artificial insemination. A majority of cattle and goats had access to pasture, and a majority of farms fed their working or producing animals concentrates; however, nutritional input was insufficient in terms of energy, protein, and micronutrient content to increase levels of production. Goat-raising was the most profitable endeavor, followed by water buffalo and cattle. We conclude that animals have the potential to contribute significantly to improved livelihoods of farmers in terms of both income generation and non-tangible benefits. However, we found that significant constraints on animal production exist, including insufficient nutritional levels and a lack of preventative care resulting in animal disease. Furthermore, cultural considerations reflecting attitudes toward cattle shape farming in ways that may limit production. Nevertheless, targeted interventions that improve animal health and productivity are possible without being cost prohibitive.

Use of decision analysis to evaluate the delivery method of veterinary health care on dairy farms as measured by correction of left displaced abomasum.

OBJECTIVE: To use decision and sensitivity analysis to examine the delivery of health care on US dairy farms as measured by correction of left displaced abomasum (LDA). SAMPLE POPULATION: 5 journal articles evaluating outcomes from veterinarian- or herd personnel-delivered correction of LDA via laparotomy or a roll-and-toggle procedure. DESIGN: Economic analysis. PROCEDURES: A decision tree was constructed on the basis of published outcome data for correction of LDAs performed by veterinarians and herd personnel. Sensitivity of the model to changing input assumptions was evaluated via an indifference curve and tornado graph. RESULTS: Decision tree analysis revealed that correction of an LDA provided by herd personnel had an expected economic advantage of $76, compared with correction provided by a veterinarian. Sensitivity of this analysis to variations in inputs indicated that changes of 2 input levels would shift the advantage to veterinarian-provided correction: a reduction (from 0.74 to 0.62) in the probability of success for correction provided by herd personnel or an increase (from 0.78 to 0.87) in the probability of success for correction provided by a veterinarian. CONCLUSIONS AND CLINICAL RELEVANCE: In this model, LDA correction by herd personnel had a significant economic advantage, compared with veterinarian-provided correction. Continued absorption of traditional veterinary tasks by unlicensed herd personnel may threaten the veterinarian-client-patient relationship (VCPR), which could have profound economic and regulatory impacts. Food animal veterinarians need to evaluate their business model to ensure they continue to provide relevant, sustainable services to their clients within the context of a valid VCPR.

Photoallergic contact dermatitis.

BACKGROUND: Photoallergic contact dermatitis (PACD) presents in patients after certain exogenous agents come into contact with the skin in the presence of ultraviolet and/or visible light. The best method currently available for investigating PACD is photopatch testing. However, photopatch testing as an investigation is under-used by clinicians, and therefore PACD may go undetected in many patients. PURPOSE: To highlight the importance of PACD and photopatch testing when investigating patients with a photo-exposed site dermatosis. METHOD: A comprehensive review of the available literature relating to PACD and photopatch testing. RESULTS: Experimental evidence suggests that PACD is a delayed type hypersensitivity reaction. Various agents have been historically shown to cause PACD, but currently the most common photosensitizers are sunscreens and topical non-steroidal anti-inflammatory drugs. Photopatch testing has in the past been subject to differing methodologies; however, a European consensus methodology now exists and should allow a greater comparison of results across centres. As chemical, pharmaceutical, and cosmetic industries produce new agents, photopatch testing of such agents in humans before release in the marketplace may prevent widespread contact with potent photosensitizers. It will also be important for ongoing multi-centre studies of existing agents to be conducted in order to keep the photopatch test batteries used by clinicians investigating PACD up to date.

A double-blind, randomized assessment of the irritant potential of sunscreen chemical dilutions used in photopatch testing.

BACKGROUND: The maximum concentration of organic sunscreen filters in current usage that does not lead to irritant reactions when performing photopatch testing is not known. Such irritant reactions can be misinterpreted as positive photoallergic contact dermatitis reactions. OBJECTIVE: To determine the frequency of irritant reactions to 19 organic sunscreen filters in current use. PATIENTS/METHODS: Ninety-four healthy volunteers were photopatch tested using the European consensus methodology to three different concentrations (2%, 5%, and 10%) of 19 organic sunscreen filters at the Photobiology Unit in Dundee, UK. RESULTS: Of the 94 subjects recruited, 80 were analysed after withdrawals and exclusions. Of the 19 organic sunscreen filters studied, only 2 compounds led to irritant reactions in > or =5% subjects. Five per cent and 10% benzophenone-4 led to irritant reactions in four and six subjects, respectively. Five per cent methylene bis-benzotriazolyl tetramethylbutylphenol led to irritant reactions in six subjects, but unlike benzophenone-4, this was not in a dose-dependent fashion. CONCLUSIONS: When performing photopatch testing according to the European consensus methodology with these 19 organic sunscreen filters, a 10% concentration is suitable for all filters, except benzophenone-4, which should be tested at a concentration of 2%.

Trends in gender, employment, salary, and debt of graduates of US veterinary medical schools and colleges.

OBJECTIVE: To characterize trends in gender, employment, starting salaries, and educational debt of graduates of US veterinary medical schools and colleges from 1988 to 2007. DESIGN: Meta-analysis. Sample Population-Veterinary medical graduates from 26 or 27 of 27 US veterinary schools and colleges from 1988 through 2007. PROCEDURES: Data were obtained from surveys published in the JAVMA. A chi2 test for trend was used to analyze trends in choices of employment and educational indebtedness for the veterinary graduate populations over time. RESULTS: The greatest changes in employment occurred in predominantly large animal practice, which attracted 10.7% of new graduates in 1989 but only 2.2% in 2007, and in advanced study, which attracted 15.2% of new graduates in 1989 and 36.8% in 2007. In 2007, 75% of graduates were women, but this gender shift was not associated with the decline in the percentage of graduates entering rural practice. From 1989 through 2007, starting salaries in private practice increased at a rate of 4.60%/y. During the same period, educational debt increased at an annual rate of 7.36%, or 60% higher than the rate of increases for starting salaries. As a result, debt at graduation increased from 1.1 times the starting salary in 1989 to 2.0 times the starting salary in 2007. CONCLUSIONS AND CLINICAL RELEVANCE: Veterinary students are now more in debt than they have ever been. This trend together with a substantial increase in the rate of interest charged for government-backed education loans create conditions for new graduates that appear unsustainable.

Feasibility of a telemedicine 'booth' for supporting remote care in Scotland.

Access to health care in remote settings is becoming increasingly difficult in Scotland. We have investigated the feasibility of a telemedicine 'booth'. Two telemedicine booths were constructed for display at the Royal Highland Show in Edinburgh. One was equipped for patient use and one for the doctor. The booths contained videoconferencing and physiological monitoring equipment connected via an IP link at a bandwidth of 1.1 Mbit/s. The picture resolution was 4CIF (704 x 576 pixels). A total of 238 members of the public used the booth for a teleconsultation with a doctor. Ninety-three percent completed questionnaires. Of the 221 respondents, 75% saw the booth as an opportunity to access specialist advice; 84% felt that the booth would save them attending a hospital or clinic; 60% felt that it would improve the way they looked after their own health. The concept of a telemedicine booth appears both feasible and acceptable to the public.