Role of hospital strain in determining outcomes for people hospitalised with COVID-19 in England.

BACKGROUND: In England, reported COVID-19 mortality rates increased during winter 2020/21 relative to earlier summer and autumn months. This study aimed to examine the association between COVID-19-related hospital bed-strain during this time and patient outcomes. METHODS: This was a retrospective observational study using Hospital Episode Statistics data for England. All unique patients aged ≥18 years in England with a diagnosis of COVID-19 who had a completed (discharged alive or died in hospital) hospital stay with an admission date between 1 July 2020 and 28 February 2021 were included. Bed-strain was calculated as the number of beds occupied by patients with COVID-19 divided by the maximum COVID-19 bed occupancy during the study period. Bed-strain was categorised into quartiles for modelling. In-hospital mortality was the primary outcome of interest and length of stay a secondary outcome. RESULTS: There were 253 768 unique hospitalised patients with a diagnosis of COVID-19 during a hospital stay. Patient admissions peaked in January 2021 (n=89 047), although the crude mortality rate peaked slightly earlier in December 2020 (26.4%). After adjustment for covariates, the mortality rate in the lowest and highest quartile of bed-strain was 23.6% and 25.3%, respectively (OR 1.13, 95% CI 1.09 to 1.17). For the lowest and the highest quartile of bed-strain, adjusted mean length of stay was 13.2 days and 11.6 days, respectively in survivors and was 16.5 days and 12.6 days, respectively in patients who died in hospital. CONCLUSIONS: High levels of bed-strain were associated with higher in-hospital mortality rates, although the effect was relatively modest and may not fully explain increased mortality rates during winter 2020/21 compared with earlier months. Shorter hospital stay during periods of greater strain may partly reflect changes in patient management over time.

"From taboo to routine": a qualitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse.

BACKGROUND: Health services are often the first point of professional contact for people who have experienced domestic violence and abuse. We report on the evaluation of a multi-site, hospital-based advocacy intervention for survivors of domestic violence and abuse. Independent Domestic Violence Advisors (IDVAs), who provide survivors with support around safety, criminal justice, and health and wellbeing, were located in five hospitals in England between 2012 and 2015 in emergency departments and maternity services. We present views about IDVAs' approaches to tackling domestic violence and abuse, how the IDVA service worked in practice, and factors that hindered and facilitated engagement with survivors. METHODS: We adopted a convenience sampling approach and invited participation from all who offered to take part within the study timeframe. Sixty-four healthcare professionals, IDVAs, IDVA service managers, and commissioners at all sites were interviewed. Interviews were analysed using a thematic approach: familiarising ourselves with the data through repeated readings and noting initial ideas; generating initial codes through double coding notable features of the data across the dataset; collating codes into potential themes; and reviewing themes to ensure they captured the essence of the data. RESULTS: Two key themes emerged. The first was Hospital-based IDVAs fulfil several crucial roles. This theme highlighted that healthcare professionals thought the hospital-based IDVA service was valuable because it enhanced their skills, knowledge, and confidence in asking about domestic violence and abuse. It enabled them to immediately refer and provide support to patients who might have otherwise been lost along a referral pathway. It also reached survivors who might otherwise have remained hidden. The second theme was Success hinges on a range of structural factors. This theme illustrated the importance of ongoing domestic violence and abuse training for staff, the IDVA having private and dedicated space, and the service being embedded in hospital infrastructure (e.g. featuring it in hospital-wide policies and enabling IDVAs access to medical records). CONCLUSION: Hospital-based IDVAs offer a unique and valued way to respond to domestic violence and abuse in a healthcare setting. Further work must now be done to explore how to implement the service sustainably.

Half a century of continuous pacing: a living witness to the evolution of a technology.

To chart the development of pacing technology and its pitfalls we present the experience of a patient who has benefitted from it but also suffered as a result of it from its earliest days. A 53-year-old physician was referred to us with obstruction of the superior and inferior vena cava on a background of more than 50 years of continuous ventricular pacing and 24 previous pacemaker-related interventions. In a single surgical procedure, his existing pacing system and redundant leads were extracted, the superior vena cava was reconstructed, and a new biventricular pacing system with epicardial leads was implanted. Pacemakers can maintain life and preserve the quality of life for many decades. The quality of this therapy has improved due to advances in the technology and in techniques. Maintaining safe pacing in the very long term requires labour, patience, and ingenuity.

Cry for health: a quantitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse.

BACKGROUND: Domestic violence and abuse (DVA) damages the health of survivors and increases use of healthcare services. We report findings from a multi-site evaluation of hospital-based advocacy services, designed to support survivors attending emergency departments and maternity services. METHODS: Independent Domestic Violence Advisors (IDVA) were co-located in five UK hospitals. Case-level data were collected at T1 (initial referral) and T2 (case closure) from survivors accessing hospital (T1 N = 692; T2 N = 476) and community IDVA services (T1 N = 3544; T2 N = 2780), used as a comparator. Measures included indicators of sociodemographic characteristics, experience of abuse, health service use, health and safety outcomes. Multivariate analyses tested for differences in changes in abuse, health and factors influencing safety outcomes. Health service use data in the 6 months pre-and post- intervention were compared to generate potential cost savings by hospital IDVA services. RESULTS: Hospital IDVAs worked with survivors less visible to community IDVA services and facilitated intervention at an earlier point. Hospital IDVAs received higher referrals from health services and enabled access to a greater number of health resources. Hospital survivors were more likely to report greater reductions in and cessation of abuse. No differences were observed in health outcomes for hospital survivors. The odds of safety increased two-fold if hospital survivors received over five contacts with an IDVA or accessed six or more resources / programmes over a longer period of time. Six months preceding IDVA intervention, hospital survivors cost on average £2463 each in use of health services; community survivors cost £533 each. The cost savings observed among hospital survivors amounted to a total of £2050 per patient per year. This offset the average cost of providing hospital IDVA services. CONCLUSIONS: Hospital IDVAs can identify survivors not visible to other services and promote safety through intensive support and access to resources. The co-location of IDVAs within the hospital encouraged referrals to other health services and wider community agencies. Further research is required to establish the cost-effectiveness of hospital IDVA services, however our findings suggest these services could be an efficient use of health service resources.

Non-laser percutaneous extraction of pacemaker and defibrillation leads: a decade of progress.

AIMS: Non-laser-based methods are safe in lead extraction but in the past have been less effective than laser methods. In the past decade, new equipment has been introduced including the Evolution® Mechanical Dilator Sheath and the Evolution® RL. We sought to determine the impact of new equipment on outcome in mechanical lead extraction. METHODS AND RESULTS: We considered 288 consecutive patients (age 66 ± 18 years) who underwent transvenous lead extraction (TLE) of 522 leads in the decade to the end of 2014. Three groups were identified: Group 1 (pre-Evolution® period, 76 patients, 133 leads), Group 2 (original Evolution® period, 115 patients, 221 leads), and Group 3 (Evolution® RL period, 97 patients, 168 leads). The age of leads was significantly greater in Groups 2 and 3 (6.2 ± 4.4 and 6.1 ± 5.4 years vs.4.7 ± 4.5, P < 0.05) as was the proportion of implantable cardioverter defibrillator leads (27.2 and 28.9 vs. 14.3%, P < 0.05). The groups were similar in the number of leads extracted per patient. Despite the increasing complexity of the systems extracted, complete extraction was achieved in a progressively greater proportion of leads (88.0% in Group 1, 95.5% in Group 2, and 97.6% in Group 3, P < 0.05), and procedure duration was similar. The proportion of leads for which femoral access was required was greater in Group 3 (11%, 18/164) compared with Group 2 (3%, 7/211), P = 0.006. The only major complications were a post-procedure subacute tamponade in Group 1 and an oesophageal injury related to transoesophageal echocardiography in Group 3. CONCLUSION: With current equipment, mechanical extraction provides a good combination of efficacy and safety.

Frozen embryos? Torpor during pregnancy in the Tasmanian short-beaked echidna Tachyglossus aculeatus setosus.

We studied the interaction between torpor and reproduction in free-ranging female Tasmanian echidnas using a combination of techniques including urogenital smears, hormone analysis, ultrasonography, external temperature loggers and camera traps. Male echidnas initiated mating activity by locating hibernating females. All females that mated or were disturbed by males prior to July 27 re-entered hibernation, including many that were pregnant. Pregnant females only entered hibernation in early pregnancy when plasma progesterone concentrations were about twice basal and progesterone then remained constant during torpor. By re-entering hibernation pregnant females extended their gestation period and delayed egg-laying. Progesterone peaked 4-6days before egg-laying, then dropped rapidly.

Is OperaVOX a clinically useful tool for the assessment of voice in a general ENT clinic?

BACKGROUND: Objective acoustic analysis is a key component of multidimensional voice assessment. OperaVOX is an iOS app which has been shown to be comparable to Multi Dimensional Voice Program for most principal measures of vocal function. As a relatively cheap, portable and easily accessible form of acoustic analysis, OperaVOX may be more clinically useful than laboratory-based software in many situations. This study aims to determine whether correlation exists between acoustic measurements obtained using OperaVOX, and perceptual evaluation of voice. METHODS: Forty-four voices from the multidisciplinary voice clinic were examined. Each voice was assessed blindly by a single experienced voice therapist using the GRBAS scale, and analysed using OperaVOX. The Spearman rank correlation co-efficient was calculated between each element of the GRBAS scale and acoustic measurements obtained by OperaVOX. RESULTS: Significant correlations were identified between GRBAS scores and OperaVOX parameters. Grade correlated significantly with jitter (ρ = 0.495, p < 0.05), shimmer (ρ = 0.385, p < 0.05), noise-to-harmonic ratio (NHR; ρ = 0.526, p < 0.05) and maximum phonation time (MPT; ρ = -0.415, p < 0.05). Roughness did not correlate with any of the measured variables. Breathiness correlated significantly with jitter (ρ = 0.342, p < 0.05), NHR (ρ = 0.344, p < 0.05) and MPT (ρ = -0.336, p < 0.05). Aesthenia correlated with NHR (ρ = 0.413, p < 0.05) and MPT (ρ = -0.399, p < 0.05). Strain correlated with Jitter (ρ = 0.560, p < 0.05), NHR (ρ = 0.600, p < 0.05) and MPT (ρ = -0.356, p < 0.05). CONCLUSIONS: OperaVOX provides objective acoustic analysis which has shown statistically significant correlation to perceptual evaluation using the GRBAS scale. The accessibility of the software package makes it possible for a wide range of health practitioners, e.g. general ENT surgeons, vascular surgeons, thyroid surgeons and cardiothoracic surgeons to objectively monitor outcomes and complications of surgical procedures that may affect vocal function. Given the increasing requirement for surgeons to monitor their outcomes as part of the move towards 'surgeon reported outcomes' this may become an invaluable tool towards that goal.

Loss-of-function mutations in the gene encoding filaggrin cause ichthyosis vulgaris.

Ichthyosis vulgaris (OMIM 146700) is the most common inherited disorder of keratinization and one of the most frequent single-gene disorders in humans. The most widely cited incidence figure is 1 in 250 based on a survey of 6,051 healthy English schoolchildren. We have identified homozygous or compound heterozygous mutations R501X and 2282del4 in the gene encoding filaggrin (FLG) as the cause of moderate or severe ichthyosis vulgaris in 15 kindreds. In addition, these mutations are semidominant; heterozygotes show a very mild phenotype with incomplete penetrance. The mutations show a combined allele frequency of approximately 4% in populations of European ancestry, explaining the high incidence of ichthyosis vulgaris. Profilaggrin is the major protein of keratohyalin granules in the epidermis. During terminal differentiation, it is cleaved into multiple filaggrin peptides that aggregate keratin filaments. The resultant matrix is cross-linked to form a major component of the cornified cell envelope. We find that loss or reduction of this major structural protein leads to varying degrees of impaired keratinization.

Common loss-of-function variants of the epidermal barrier protein filaggrin are a major predisposing factor for atopic dermatitis.

Atopic disease, including atopic dermatitis (eczema), allergy and asthma, has increased in frequency in recent decades and now affects approximately 20% of the population in the developed world. Twin and family studies have shown that predisposition to atopic disease is highly heritable. Although most genetic studies have focused on immunological mechanisms, a primary epithelial barrier defect has been anticipated. Filaggrin is a key protein that facilitates terminal differentiation of the epidermis and formation of the skin barrier. Here we show that two independent loss-of-function genetic variants (R510X and 2282del4) in the gene encoding filaggrin (FLG) are very strong predisposing factors for atopic dermatitis. These variants are carried by approximately 9% of people of European origin. These variants also show highly significant association with asthma occurring in the context of atopic dermatitis. This work establishes a key role for impaired skin barrier function in the development of atopic disease.

Personal academic tutors (PATs): A student perspective.

INTRODUCTION: Personal academic tutors (PATs) have an important role in providing academic and non-academic support for university students. This study sought to assess the effectiveness of a PAT system developed for pharmacy students. METHODS: A student-led survey was developed using a mix of single answer, Likert-style scale, and free text responses. The questionnaire was peer reviewed by students and other researchers and was piloted before being made available online to pharmacy students. RESULTS: One hundred fifty-nine responses were received from students across all stages of the programme. In general, students expressed high levels of satisfaction with their PATs. Despite high levels of recognition of positive attributes of the PAT system, students had low levels of willingness to discuss personal issues with their PAT. Male students were more comfortable than female students in discussing personal issues. The level of comfort expressed by female participants was not significantly different with male or female PATs. Often students turn to friends and family who may provide advice that is unhelpful or outdated, particularly for issues such as poor mental health. Reasons for not speaking to PATs included concerns about being judged and academic records being affected. Worryingly, 18% of respondents (n = 28) had personal issues that had not been disclosed to anyone. CONCLUSIONS: Satisfaction with more traditional academic tutoring was high but the reluctance to discuss wellbeing issues was concerning. Further work involving the student body is planned to co-create strategies to overcome reluctance to discuss personal issues.

Domestic and Family Violence Screening and Response: A Prospective, Cross-Sectional, Mixed Methods Survey in Private Mental Health Clients.

Most domestic and family violence (DFV) research has focused on establishing prevalence and screening rates in public health and community samples. This study sought to address a gap in the literature by evaluating DFV screening and response practices in a private mental healthcare inpatient service and determining if clients of the service had unmet DFV needs. A prospective, convenience sample, mixed methods, cross-sectional survey of adult inpatient mental health consumers was employed. Sixty-two participants completed the Royal Melbourne Hospital Patient Family Violence Survey. Quantitative Likert-type and categorical responses were collated and analysed descriptively (count and percentage). Free-text responses were analysed using qualitative description within a content analysis framework. Sixty-five percent of participants had been screened for at least one DFV issue, on at least one occasion, with 35% not being screened, to their recall. Twenty-three percent reported disclosing DFV concerns, 82% felt very supported by the clinician's response to their disclosure, and 86% were provided with information they found helpful. Unmet needs were identified in 13% of participants, who had wanted to disclose DFV concerns but not feel comfortable to do so. No unscreened respondents disclosed DFV concerns, highlighting the need to uphold best practice guidelines for direct enquiry. Most disclosing clients were positive about the support they received. Indicated areas for improvement were screening rates, active follow-up, increasing psychology support levels and safety planning.

Lessons learnt from the implementation of the Covid-19 vaccination programme in the Southwest of England.

BACKGROUND: Vaccination remains one of the most successful public health interventions in preventing severe disease and death. The roll-out of Covid-19 vaccination programmes has helped protect billions of people around the world against Covid-19. Most of these programmes have been unprecedented in terms of scale and resources, and have been implemented at times of significant humanitarian crisis. This study aims to outline the lessons learnt from the implementation of a regional Covid-19 vaccination programme. These will help inform emergency preparedness and future crisis management. METHODS: This qualitative study sought to explore the key drivers to the successful implementation of the Covid-19 vaccination programme in a region in the Southwest of England, applying the Normalisation Process Theory lens (NPT) to examine multi-stakeholder perspectives. Data collection involved semi-structured interviews with 75 participants. Document analysis was also used to corroborate the findings emerging from the interviews. Inductive thematic analysis of the data was used to identify the key drivers for the successful implementation of the programme. The NPT lens was then applied to map the themes identified to the domains and constructs of the framework. RESULTS: Ten key drivers to the successful implementation of the Covid-19 vaccination programme locally were identified, including: the clarity and consistency of the programme's goal; the diverse representation of stakeholders within the programme leadership team and the mechanisms created by this team to ensure psychological safety, autonomy, operational flexibility and staff empowerment; Communication and data specialists' input, and collaboration with local communities to maximise the reach of the programme; and allocating funding to tackle health inequalities. CONCLUSIONS: This study highlights the lessons learnt from the implementation of the Covid-19 vaccination programme at a local level, and the mechanisms that can be used in future crises to respond efficiently to the needs of individuals, communities and governments.

The 5'-3' exoribonuclease Pacman (Xrn1) regulates expression of the heat shock protein Hsp67Bc and the microRNA miR-277-3p in Drosophila wing imaginal discs.

Pacman/Xrn1 is a highly conserved exoribonuclease known to play a critical role in gene regulatory events such as control of mRNA stability, RNA interference and regulation via miRNAs. Although Pacman has been well studied in Drosophila tissue culture cells, the biologically relevant cellular pathways controlled by Pacman in natural tissues are unknown. This study shows that a hypomorphic mutation in pacman (pcm (5)) results in smaller wing imaginal discs. These tissues, found in the larva, are known to grow and differentiate to form wing and thorax structures in the adult fly. Using microarray analysis, followed by quantitative RT-PCR, we show that eight mRNAs were increased in level by>2-fold in the pcm5 mutant wing discs compared with the control. The levels of pre-mRNAs were tested for five of these mRNAs; four did not increase in the pcm (5) mutant, showing that they are regulated at the post-transcriptional level and, therefore, could be directly affected by Pacman. These transcripts include one that encodes the heat shock protein Hsp67Bc, which is upregulated 11.9-fold at the post-transcriptional level and 2.3-fold at the protein level. One miRNA, miR-277-3p, is 5.6-fold downregulated at the post-transcriptional level in mutant discs, suggesting that Pacman affects its processing in this tissue. Together, these data show that a relatively small number of mRNAs and miRNAs substantially change in abundance in pacman mutant wing imaginal discs. Since Hsp67Bc is known to regulate autophagy and protein synthesis, it is possible that Pacman may control the growth of wing imaginal discs by regulating these processes.

Breast microcalcification: diagnostic value of calcified and non-calcified cores on specimen radiographs.

To determine if the specimen without calcification, as depicted on specimen radiography, made any contribution to the final histopathological diagnosis in comparison to the specimen with calcification. The records of 1312 stereotactic vacuum-assisted biopsies for breast microcalcifications between February 2000 and December 2010 were reviewed retrospectively. Following specimen x-ray the biopsy tissues with and without microcalcifications were sent in two separate pots (pot 1 and pot 2 respectively). The number of cores in each pot and the number of calcium specks within the cores were recorded. In 1135 of the 1312 (86%) cases the histopathological findings were similar for pot 1 and pot 2. In 165 cases (13%) the diagnosis was made solely on pot 1 while cores in pot 2 did not reveal any additional pathology. In 12 biopsies (1%) the significant pathology was only present in the specimen without any calcification. For "microcalcification only" breast lesions the specimen containing calcium will yield a correct diagnosis in 99% of cases. Cores containing no calcification rarely contribute to the diagnosis on their own, but in 87% of cases an accurate diagnosis would still have been made even if the targeted calcification had been missed.

Therapeutic patient education in atopic dermatitis: worldwide experiences.

Therapeutic patient education (TPE) has proven effective in increasing treatment adherence and improving quality of life (QoL) for patients with numerous chronic diseases, especially atopic dermatitis (AD). This study was undertaken to identify worldwide TPE experiences in AD treatment. Experts from 23 hospitals, located in 11 countries, responded to a questionnaire on 10 major items. Patients in TPE programs were mainly children and adolescents with moderate to severe AD or markedly affected QoL. Individual and collective approaches were used. Depending on the center, the number of sessions varied from one to six (corresponding to 2 to 12 hours of education), and 20 to 200 patients were followed each year. Each center's education team comprised multidisciplinary professionals (e.g., doctors, nurses, psychologists). Evaluations were based on clinical assessment, QoL, a satisfaction index, or some combination of the three. When funding was obtained, it came from regional health authorities (France), insurance companies (Germany), donations (United States), or pharmaceutical firms (Japan, Italy). The role of patient associations was always highlighted, but their involvement in the TPE process varied from one country to another. Despite the nonexhaustive approach, our findings demonstrate the increasing interest in TPE for managing individuals with AD. In spite of the cultural and financial differences between countries, there is a consensus among experts to integrate education into the treatment of eczema.

Managing childhood eczema: qualitative study exploring carers' experiences of barriers and facilitators to treatment adherence.

AIM: To explore parents and carers' experiences of barriers and facilitators to treatment adherence in childhood eczema BACKGROUND: Childhood eczema is common and causes significant impact on quality of life for children and their families, particularly due to sleep disturbance and itch. Non-adherence to application of topical treatments is the main cause of treatment failure. DESIGN: Qualitative interview study. METHODS: Qualitative interviews were carried out with 31 carers from 28 families of children with eczema. Participants were recruited through primary care and included if they had a child aged 5 or less with a diagnosis of eczema. Interviews were carried out between December 2010-May 2011. Data were analysed using a constant comparative approach. FINDINGS: Barriers to treatment adherence included carer beliefs around eczema treatment, the time consuming nature of applying topical treatments, and child resistance to treatment. Families employed a range of strategies in an attempt to work around children's resistance to treatment with varying success. Strategies included involving the child in treatment, distracting the child during treatment, or making a game of it, using rewards, applying treatment to a sleeping child or, in a few cases, physically restraining the child. Some carers reduced frequency of applications in an attempt to reduce child resistance. CONCLUSIONS: Regular application of topical treatments to children is an onerous task, particularly in families where child resistance develops. Early recognition and discussion of resistance and better awareness of the strategies to overcome this may help carers to respond positively and avoid establishing habitual confrontation.

Our experience in developing and operating the Airway Intervention Registry for Recurrent Respiratory Papillomatosis (AIR-RRP): national data collection [version 2; peer review: 2 approved].

Recurrent respiratory papillomatosis (RRP) is characterised by benign wart-like growths in the respiratory tract caused by the human papillomavirus (HPV). These warts vary in size and grow quickly, causing voice changes and airway obstruction. Whilst the condition is rare, RRP is more common and aggressive in children. There is currently no curative treatment for HPV, therefore RRP is managed by maintaining a safe airway and a serviceable voice by repeated surgery to remove the growths. A lack of specific diagnostic codes prevents reliable case ascertainment of RRP from routine administrative databases such as Hospital Episode Statistics. In 2017 a cross-sectional survey identified 918 RRP patients in the UK, half of whom had received surgical intervention for RRP in the previous 12 months with 16 different interventions. Randomised controlled trials for RRP interventions are difficult due to the rarity of the disease, variation in severity and progression and non-standard care across the NHS. Consequently, there is a lack of definitive efficacy and safety evidence. The only national guidance for RRP interventions is "Radiofrequency cold ablation for respiratory papillomatosis" (NICE IPG434, 2017) which recommended further data collection due to lack of evidence. However, due to the wide variation in RRP management across the NHS, clinical opinion favoured that any data collection should include a comparison of safety and efficacy of all RRP interventions in order to advise which improved patient outcomes and quality of life. To address lack of evidence, and inform the future care of RRP patients, we developed a registry and used it to collect real-world data from patients receiving treatment for RRP in NHS hospitals across the UK. The purpose of this paper is to share lessons learned from this national data collection exercise to inform future clinical registry development.

Data quality and autism: Issues and potential impacts.

INTRODUCTION: Large healthcare datasets can provide insight that has the potential to improve outcomes for patients. However, it is important to understand the strengths and limitations of such datasets so that the insights they provide are accurate and useful. The aim of this study was to identify data inconsistencies within the Hospital Episodes Statistics (HES) dataset for autistic patients and assess potential biases introduced through these inconsistencies and their impact on patient outcomes. The study can only identify inconsistencies in recording of autism diagnosis and not whether the inclusion or exclusion of the autism diagnosis is the error. METHODS: Data were extracted from the HES database for the period 1st April 2013 to 31st March 2021 for patients with a diagnosis of autism. First spells in hospital during the study period were identified for each patient and these were linked to any subsequent spell in hospital for the same patient. Data inconsistencies were recorded where autism was not recorded as a diagnosis in a subsequent spell. Features associated with data inconsistencies were identified using a random forest classifiers and regression modelling. RESULTS: Data were available for 172,324 unique patients who had been recorded as having an autism diagnosis on first admission. In total, 43.7 % of subsequent spells were found to have inconsistencies. The features most strongly associated with inconsistencies included greater age, greater deprivation, longer time since the first spell, change in provider, shorter length of stay, being female and a change in the main specialty description. The random forest algorithm had an area under the receiver operating characteristic curve of 0.864 (95 % CI [0.862 - 0.866]) in predicting a data inconsistency. For patients who died in hospital, inconsistencies in their final spell were significantly associated with being 80 years and over, being female, greater deprivation and use of a palliative care code in the death spell. CONCLUSIONS: Data inconsistencies in the HES database were relatively common in autistic patients and were associated a number of patient and hospital admission characteristics. Such inconsistencies have the potential to distort our understanding of service use in key demographic groups.

Towards global consensus on outcome measures for atopic eczema research: results of the HOME II meeting.

The use of nonstandardized and inadequately validated outcome measures in atopic eczema trials is a major obstacle to practising evidence-based dermatology. The Harmonising Outcome Measures for Eczema (HOME) initiative is an international multiprofessional group dedicated to atopic eczema outcomes research. In June 2011, the HOME initiative conducted a consensus study involving 43 individuals from 10 countries, representing different stakeholders (patients, clinicians, methodologists, pharmaceutical industry) to determine core outcome domains for atopic eczema trials, to define quality criteria for atopic eczema outcome measures and to prioritize topics for atopic eczema outcomes research. Delegates were given evidence-based information, followed by structured group discussion and anonymous consensus voting. Consensus was achieved to include clinical signs, symptoms, long-term control of flares and quality of life into the core set of outcome domains for atopic eczema trials. The HOME initiative strongly recommends including and reporting these core outcome domains as primary or secondary endpoints in all future atopic eczema trials. Measures of these core outcome domains need to be valid, sensitive to change and feasible. Prioritized topics of the HOME initiative are the identification/development of the most appropriate instruments for the four core outcome domains. HOME is open to anyone with an interest in atopic eczema outcomes research.

Domestic and family violence knowledge and skills: A private mental health service survey of nurses, allied health, and medical clinicians.

Mental healthcare services have an important role to play in recognizing and responding to domestic and family violence (DFV). This study aimed to evaluate staff knowledge, confidence, and clinical skills in family violence in an Australian private mental healthcare service. The methodology utilized was a cross-sectional, online survey of clinical staff. In total, 93 clinical staff participated (51 nursing, 37 allied health, and 5 medical), with a 29% response rate. Most clinicians reported working with patients who had disclosed experiencing family violence, but the majority of clinicians (63%) had received no training in the area, with nurses reporting the lowest training levels. Less than 20% reported definitive knowledge of important clinical skills including key family violence indicators, asking about family violence, and responding to disclosures. However, qualitative text response data indicated that many clinicians would provide responses that encompassed best-practice recommendations. Overall, the results indicated suboptimal clinician family violence knowledge, with further training needed, particularly in nursing staff. Stronger knowledge and skills in social workers and psychologists, relative to nurses, paralleled existing research in a medical hospital sample. The data from the study will be utilized to inform the implementation of a hospital-wide quality and service improvement project in the area of DFV clinical response.