The effect of deprivation and HbA1c on admission to hospital for diabetic ketoacidosis in type 1 diabetes.

AIMS/HYPOTHESIS: Diabetic ketoacidosis is a potentially life-threatening complication of diabetes and has a strong relationship with HbA(1c). We examined how socioeconomic group affects the likelihood of admission to hospital for diabetic ketoacidosis. METHODS: The Scottish Care Information - Diabetes Collaboration (SCI-DC), a dynamic national register of all cases of diagnosed diabetes in Scotland, was linked to national data on hospital admissions. We identified 24,750 people with type 1 diabetes between January 2005 and December 2007. We assessed the relationship between HbA(1c) and quintiles of deprivation with hospital admissions for diabetic ketoacidosis in people with type 1 diabetes adjusting for patient characteristics. RESULTS: We identified 23,479 people with type 1 diabetes who had complete recording of covariates. Deprivation had a substantial effect on odds of admission to hospital for diabetic ketoacidosis (OR 4.51, 95% CI 3.73, 5.46 in the most deprived quintile compared with the least deprived). This effect persisted after the inclusion of HbA(1c) and other risk factors (OR 2.81, 95% CI 2.32, 3.39). Men had a reduced risk of admission to hospital for diabetic ketoacidosis (OR 0.71, 95% CI 0.63, 0.79) and those with a history of smoking had increased odds of admission to hospital for diabetic ketoacidosis by a factor of 1.55 (95% CI 1.36, 1.78). CONCLUSIONS/INTERPRETATION: Women, smokers, those with high HbA(1c) and those living in more deprived areas have an increased risk of admission to hospital for diabetic ketoacidosis. The effect of deprivation was present even after inclusion of other risk factors. This work highlights that those in poorer areas of the community with high HbA(1c) represent a group who might be usefully supported to try to reduce hospital admissions.

Contribution of neuropsychiatric symptoms in Parkinson's disease to different domains of caregiver burden.

INTRODUCTION: Caregiver burden is high among caregivers of PD patients (CPD). Neuropsychiatric symptoms are leading contributors to CPD burden, but whether different symptoms differentially impact domains of caregiver burden is not known. Our objective was to examine which neuropsychiatric symptoms and demographic factors contribute to different domains of caregiver burden in PD. METHODS: This was a cross-sectional online survey study. Participants were recruited from the Fox Insight (FI) study and were eligible if they identified themselves as a CPD. The primary outcome was the Caregiver Burden Inventory (CBI) total score and its 5 sub-domain scores. The Neuropsychiatric Inventory Questionnaire (NPI-Q) assessed caregiver-reported neuropsychiatric symptoms in the care recipient. Multivariable linear regression models were used to characterize the associations between NPI-Q symptom severity scores and CBI scores. Covariates were caregiver age, sex, education, and caregiving duration. RESULTS: The sample consisted of 450 CPD, mean age 65.87 (SD 10.39) years, 74% females. After adjusting for covariates, CBI total score was predicted by NPI-Q total score (ß = 1.96, p < 0.001); model adjusted R2 = 39.2%. Anxiety severity had the largest effect size [standardized ß (sß) = 0.224] on the time-dependency domain, which was also associated with female sex (sß = - 0.133) and age (sß = 0.088). Severity of disinhibition (sß = 0.218), agitation (sß = 0.199), and female sex (sß = 0.104) were associated with greater emotional burden. CONCLUSION: Our findings indicate that demographic characteristics and specific neuropsychiatric symptoms contribute differentially to domains of caregiver burden. Tailored interventions to support CPD are needed.

A computer tool for a minimax criterion in binary response and heteroscedastic simple linear regression models.

BACKGROUND AND OBJECTIVE: Binary response models are used in many real applications. For these models the Fisher information matrix (FIM) is proportional to the FIM of a weighted simple linear regression model. The same is also true when the weight function has a finite integral. Thus, optimal designs for one binary model are also optimal for the corresponding weighted linear regression model. The main objective of this paper is to provide a tool for the construction of MV-optimal designs, minimizing the maximum of the variances of the estimates, for a general design space. METHODS: MV-optimality is a potentially difficult criterion because of its nondifferentiability at equal variance designs. A methodology for obtaining MV-optimal designs where the design space is a compact interval [a, b] will be given for several standard weight functions. RESULTS: The methodology will allow us to build a user-friendly computer tool based on Mathematica to compute MV-optimal designs. Some illustrative examples will show a representation of MV-optimal designs in the Euclidean plane, taking a and b as the axes. The applet will be explained using two relevant models. In the first one the case of a weighted linear regression model is considered, where the weight function is directly chosen from a typical family. In the second example a binary response model is assumed, where the probability of the outcome is given by a typical probability distribution. CONCLUSIONS: Practitioners can use the provided applet to identify the solution and to know the exact support points and design weights.

Assessment of the outcome of low back surgery.

We aimed to develop a better understanding and method of rating the success or failure of low back surgery by studying 185 patients prospectively. Identical pre-operative and postoperative assessment by an independent observer included pain, disability, physical impairment, psychological distress and illness behaviour. Outcome was assessed by the patient, by the observer and by return to work. There was 96% follow-up at two years. Correlation co-efficients varied considerably between the various measures of outcome, both patient and observer appearing to base their assessment mainly on postoperative status rather than on any change produced by surgery. The observer was influenced most by postoperative pain, disability and physical impairment. Patients were influenced most by residual physical impairment, type of surgery and proportional change in disability. Return to work was moderately influenced by postoperative disability and to a larger extent by social and work-related factors. We developed a simple formula to judge overall success or failure which accurately reproduced the combined assessment of patient and observer. If surgical audit is to be meaningful it must be based on an improved understanding of how the outcome of surgery should be assessed.

The impact of teaching on hospital costs: a budgetary approach to non-market institutions.

NHS hospitals contribute to medical education, training nurses and research, as well as to the care of patients. In the past they have been funded largely on the basis of resources employed, with additional funding for medical education and training nurses. The intellectual basis for the funding of medical education is a single econometric study of English hospitals in the financial year 1969-70. The methodology used has since been criticized, and it has been suggested that actual expenditure has been very much less than that earmarked by the health departments. New estimates are obtained using Scottish data for the financial year 1985-86. The method used is to proceed in a two-stage fashion, identifying via regression techniques variables measuring hospital activity and resources which contribute significantly to hospital costs. We then assess the significance of medical education, nurse training and hospitals' teaching status against this background. Our conclusions include: (1) actual expenditure on medical education was probably less than the funding formula allowed, but the error of margin is too large to suggest overfunding; (2) training nurses incurs significant financial costs, even after the explicit allowances made; and (3), major teaching hospitals tended to cost more, but not significantly more than their non-teaching counterparts. These financial implications for NHS hospitals should be borne in mind given the current NHS review.

Non-price allocative procedures: Scottish solutions to a National Health Service problem.

Except for a few NHS services, the allocation of resources depends on administrative-cummedical decision-making. At one level the Scottish Home and Health Department allocates funds between the fifteen health boards, at another level clinicians allocate resources between patients. We examine experience at a level intermediate between these two, and focus on the provision of two services--diagnostic radiology and ECG--at health centres. A benefit: cost framework is used to test three hypotheses about how the two services have been allocated. The three hypotheses relate to the benefits from provision and are characterised as 'medical excellence', 'equity' and 'market' orientated. Data on health centre list size and distance to alternative provision are used to test the hypotheses. The conclusions are as follows. The equity and market models are equally valid descriptions for ECG, a service provided by general practitioners. A combination of the equity and/or market model with the medical model is a valid description for diagnostic radiology, a service provided by health boards and the Scottish Home and Health Department.

An optimal design problem in rhythmometry.

A trigonometric regression model is assumed for a problem involving circadian rhythm exhibited by peak expiratory flow. Experimental designs are sought with a view to estimating a particular nonlinear function of the parameters. Both optimal and nonoptimal, but more practicable, designs are derived and their relative efficiencies are established.

The chief scientist reports... Consultant out-patient services: provision at health centres in Scotland.

Hospital based consultant (out-patient) services are most likely to be found in the community at health centres. By 1991 some 45% of the Scottish population had access to services provided at these health centres. The clinical specialties most commonly provided were psychiatry, obstetrics, paediatrics and gynaecology, and they accounted for some 10% or more of all attendances. Regular consultant visits in these and other specialties were more common at the larger health centres and at those further distant from alternative provision.

Consultant outreach, 1991 to 1998. An update and extension on its distribution in Scotland.

OBJECTIVE: To assess the extent and distribution of consultant outreach in Scotland between 1991 and 1998. DESIGN: The paper has three parts. First a description of the trends in consultants and consultant activity provides the background. This is followed by the results of an update of the 1991 survey of all health centres in Scotland and its extension to all GP premises considered suitable to hold consultant clinics. Finally, binary regression analysis of outreach is used to test the importance of total list size, distance to alternative provision and deprivation. Fourteen of the most common consultant specialties are studied. SETTING AND SUBJECTS: Scotland-wide data on consultants and consultant activity using annual data over the 1990s; and a Scotland-wide survey of 231 health centres and 312 GP premises over the period July to December 1998. RESULTS AND CONCLUSIONS: Consultant full time equivalents (ftes) increased and, with minor exceptions, consultant activity did so too. In respect of outreach, the increase was largely at GP premises and for psychiatry. For only two specialties of the fourteen studied, obstetrics and general psychiatry, could outreach be considered important. Such outreach provision as was made went where the total list size was largest and alternative provision farthest distant. The evidence that deprivation had an influence on outreach varies with specialty and is qualified.

Urine electrolyte response to 18-hydroxy-11-deoxycorticosterone in normal man.

1. To assess whether the adrenal corticosteroid 18-hydroxy-11-deoxycorticosterone [18-(OH)-DOC] affects urine electrolyte excretion in normal man, seven male volunteers received 120 microgram (353 nmol) intravenously in 1 h. This was compared with glucose (50 g/l; control) and aldosterone (80 microgram, 222 nmol) infusions in the same subjects. 2. A definite though weak antinatriuretic response to 18-(OH)DOC was observed, whereas urine potassium excretion was not altered. Aldosterone increased urine potassium excretion and reduced sodium output. Urine pH was lowered by both corticosteroids, aldosterone in general having a more marked effect. Urine volume was not altered by 18-(OH)DOC. 3. Plasma concentrations of 18-(OH)DOC and aldosterone rose approximately tenfold during their respective infusions. Compared with that of aldosterone, the metabolic clearance rate of 18-(OH)DOC was slower andits plasma half-life was longer. 4. We have been able to demonstrate that 18-(OH)DOC has a definite, albeit weak antinatriuretic action in normal man, but whether or not this corticosteroid is capable of elevating the blood pressure in man remains to be shown.

Adrenocortical hormone concentrations in children during cardiopulmonary bypass with and without pulsatile flow.

Plasma cortisol and ACTH concentrations were measured in two groups of children (aged 1-16 yr). Ten children underwent routine (non-pulsatile) cardiopulmonary bypass and 10 underwent pulsatile bypass under moderate hypothermia (28-32 degrees C). Comparable increases in cortisol and ACTH concentrations were demonstrated at the onset of bypass and the concentrations of both hormones increased during bypass. In the post-bypass period plasma cortisol concentration increased sharply; there was no further increase in the plasma ACTH concentration. By 24 h the concentrations of both hormones had declined towards baseline values. There were no significant differences between the groups.