Dynamics of SARS-CoV-2 infection hospitalisation and infection fatality ratios over 23 months in England.

The relationship between prevalence of infection and severe outcomes such as hospitalisation and death changed over the course of the COVID-19 pandemic. Reliable estimates of the infection fatality ratio (IFR) and infection hospitalisation ratio (IHR) along with the time-delay between infection and hospitalisation/death can inform forecasts of the numbers/timing of severe outcomes and allow healthcare services to better prepare for periods of increased demand. The REal-time Assessment of Community Transmission-1 (REACT-1) study estimated swab positivity for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in England approximately monthly from May 2020 to March 2022. Here, we analyse the changing relationship between prevalence of swab positivity and the IFR and IHR over this period in England, using publicly available data for the daily number of deaths and hospitalisations, REACT-1 swab positivity data, time-delay models, and Bayesian P-spline models. We analyse data for all age groups together, as well as in 2 subgroups: those aged 65 and over and those aged 64 and under. Additionally, we analysed the relationship between swab positivity and daily case numbers to estimate the case ascertainment rate of England's mass testing programme. During 2020, we estimated the IFR to be 0.67% and the IHR to be 2.6%. By late 2021/early 2022, the IFR and IHR had both decreased to 0.097% and 0.76%, respectively. The average case ascertainment rate over the entire duration of the study was estimated to be 36.1%, but there was some significant variation in continuous estimates of the case ascertainment rate. Continuous estimates of the IFR and IHR of the virus were observed to increase during the periods of Alpha and Delta's emergence. During periods of vaccination rollout, and the emergence of the Omicron variant, the IFR and IHR decreased. During 2020, we estimated a time-lag of 19 days between hospitalisation and swab positivity, and 26 days between deaths and swab positivity. By late 2021/early 2022, these time-lags had decreased to 7 days for hospitalisations and 18 days for deaths. Even though many populations have high levels of immunity to SARS-CoV-2 from vaccination and natural infection, waning of immunity and variant emergence will continue to be an upwards pressure on the IHR and IFR. As investments in community surveillance of SARS-CoV-2 infection are scaled back, alternative methods are required to accurately track the ever-changing relationship between infection, hospitalisation, and death and hence provide vital information for healthcare provision and utilisation.

International evaluation of an AI system for breast cancer screening.

Screening mammography aims to identify breast cancer at earlier stages of the disease, when treatment can be more successful1. Despite the existence of screening programmes worldwide, the interpretation of mammograms is affected by high rates of false positives and false negatives2. Here we present an artificial intelligence (AI) system that is capable of surpassing human experts in breast cancer prediction. To assess its performance in the clinical setting, we curated a large representative dataset from the UK and a large enriched dataset from the USA. We show an absolute reduction of 5.7% and 1.2% (USA and UK) in false positives and 9.4% and 2.7% in false negatives. We provide evidence of the ability of the system to generalize from the UK to the USA. In an independent study of six radiologists, the AI system outperformed all of the human readers: the area under the receiver operating characteristic curve (AUC-ROC) for the AI system was greater than the AUC-ROC for the average radiologist by an absolute margin of 11.5%. We ran a simulation in which the AI system participated in the double-reading process that is used in the UK, and found that the AI system maintained non-inferior performance and reduced the workload of the second reader by 88%. This robust assessment of the AI system paves the way for clinical trials to improve the accuracy and efficiency of breast cancer screening.

Objective Assessment of Cognitive Workload in Surgery: A Systematic Review.

OBJECTIVE: To systematically review technologies that objectively measure CWL in surgery, assessing their psychometric and methodological characteristics. SUMMARY BACKGROUND DATA: Surgical tasks involving concurrent clinical decision-making and the safe application of technical and non-technical skills require a substantial cognitive demand and resource utilization. Cognitive overload leads to impaired clinical decision-making and performance decline. Assessing cognitive workload (CWL) could enable interventions to alleviate burden and improve patient safety. METHODS: Ovid MEDLINE, OVID Embase, the Cochrane Library and IEEE Xplore databases were searched from inception to August 2023. Full-text, peer-reviewed original studies in a population of surgeons, anesthesiologists or interventional radiologists were considered, with no publication date constraints. Study population, task paradigm, stressor, Cognitive Load Theory (CLT) domain, objective and subjective parameters, statistical analysis and results were extracted. Studies were assessed for a) definition of CWL, b) details of the clinical task paradigm, and c) objective CWL assessment tool. Assessment tools were evaluated using psychometric and methodological characteristics. RESULTS: 10790 studies were identified; 9004 were screened; 269 full studies were assessed for eligibility, of which 67 met inclusion criteria. The most widely used assessment modalities were autonomic (32 eye studies and 24 cardiac). Intrinsic workload (e.g. task complexity) and germane workload (effect of training or expertize) were the most prevalent designs investigated. CWL was not defined in 30 of 67 studies (44.8%). Sensitivity was greatest for neurophysiological instruments (100% EEG, 80% fNIRS); and across modalities accuracy increased with multi-sensor recordings. Specificity was limited to cardiac and ocular metrics, and was found to be sub-optimal (50% and 66.67%). Cardiac sensors were the least intrusive, with 54.2% of studies conducted in naturalistic clinical environments (higher ecological validity). CONCLUSION: Physiological metrics provide an accessible, objective assessment of CWL, but dependence on autonomic function negates selectivity and diagnosticity. Neurophysiological measures demonstrate favorable sensitivity, directly measuring brain activation as a correlate of cognitive state. Lacking an objective gold standard at present, we recommend the concurrent use of multimodal objective sensors and subjective tools for cross-validation. A theoretical and technical framework for objective assessment of CWL is required to overcome the heterogeneity of methodological reporting, data processing, and analysis.

An SMS and animated video intervention to increase uptake of breast cancer screening: a randomised controlled trial.

BACKGROUND: Breast cancer screening attendance in the UK has fallen, and London has the lowest uptake nationally. This study tested the impact of a behavioural science-informed reminder SMS, and animated video intervention on screening uptake. METHODS: This three-armed randomised controlled trial took place in two screening services in London (each service operated across a range of static sites such as hospitals, and mobile sites). We included participants who were registered with GP as female, aged 50-70 years, and not screened in the past 3 years. We excluded those who had opted out of screening messages or were in care. Participants were assigned into three groups via the final two digits of their NHS number (ratio 34:33:33): control group (received usual care reminder), behavSMS group (behavioural science-informed SMS reminder addressing reducing negative emotions and information on health consequences), or behavSMS+video group (behavioural SMS plus link to animation). Researchers were masked to allocation. The SMS and video were co-designed with stakeholders using the Behaviour Change Wheel. Invitation processes changed during the COVID-19 pandemic, and therefore, we did separate analyses for those receiving a timed appointment (n=9027), and an open invitation to book an appointment (n=25 020). Messages were sent 7 days and 1 day before the appointment, plus 7 days after the open invitation letter. Group differences in the primary outcome of attendance within 3 months of invitation (and secondary outcome of booking for open invites) were assessed using χ2, and logistic regression controlling for age, ethnicity, deprivation, and first invitation. This trial is registered with ClinicalTrials.gov, NCT05395871. FINDINGS: Recruitment took place between July 18, and Oct 21, 2022. For timed invitations, 3094 participants were assigned to the control group, 2952 to the behavSMS group, and 2981 to the behavSMS+video group. For open invitations groups sizes were 8654, 8095, and 8271 respectively. Median age was 59 years for participants who received a timed appointment, and 58 years for those who received an open invitation. There were no attendance differences for timed appointments (intention-to-treat analysis): 71·9% (2225/3094) in control group; 69·9% (2064/2952) in behavSMS group; 71·7% (2137/2981) in behavSMS+video group (χ2(2)=3·47, p=0·176), even when controlling for covariates. There were no attendance differences for open invitations either: 7·4% (4104/8654) in control group, 8·3% (3909/8095) in behavSMS group, 48·1% (3978/8271) in behavSMS+video (χ2(2)=1·40, p=0·497), including when controlling for covariates. However, in the per-protocol analysis (of those with valid mobile numbers), intervention groups were more likely to book an appointment: 44·7% (3238/7274) in control group, 46·3% (3121/6744) in behavSMS group, and 46·3% (3199/6910) in behavSMS+video group (χ2(2)=6·01, p=0·050). INTERPRETATION: Despite positive stakeholder feedback during co-design, the SMS or SMS+video interventions did not increase breast screening attendance compared with the usual SMS reminder. A limitation is that only 5·8% participants followed the video link. Links within SMS are unlikely to be an effective way to disseminate video content, and alternative options are being explored. FUNDING: NHS England and National Institute for Health and Care Research (NIHR).

Improving the quality of written communication at patient discharge: triangulation of qualitative analyses and intervention co-design.

BACKGROUND: Poor handovers between hospital and primary care threaten safe discharges, with elderly and frail patients most at risk of harm. Using Behavioural Science we explored influences and identified relevant behaviour change techniques (BCTs) to improve written handovers and safety during discharge. METHODS: We conducted two qualitative studies: (1) ethnographic observations (>80 h) collected by five researchers in five purposively sampled clinical areas of a London teaching hospital, investigating routine work and interactions of hospital staff involved in discharges; and (2) 12 semi-structured interviews with hospital staff involved in discharge exploring influences on preparations of written handovers. Written consent was sought from clinical leads for ethnographic observations and from interview participants. Ethnographic fieldnotes and interview transcripts were thematically analysed using inductive and deductive approaches, respectively. Study findings were triangulated to identify key influences, mapped onto the Theoretical Domains Framework (TDF). We identified appropriate BCTs to address observed influences within each TDF domain using the Theory and Techniques Tool. Health-care workers (n=15), patients (n=2) and carers (n=2) selected and designed an intervention to improve written handovers in two workshops. Hospital workshop participants were involved with preparing written discharge handovers. Public participants had either recently been discharged from hospital or cared for someone recently discharged, including patients from groups especially vulnerable during discharge. FINDINGS: Triangulation of study findings generated 11 key influences on preparations of written handovers within five TDF domains: knowledge (eg, lack of awareness of guidelines), skills (staff experience), social or professional role and identity (effective communication), environmental context and resources (working patterns), and social influences (lack of feedback). 14 BCTs were identified to address these influences, including behavioural rehearsal or practice, instruction on how to perform a behaviour, and social support (practical). Workshop participants selected and designed a multifaceted educational intervention to improve written handovers. INTERPRETATION: The quality of handover documentation prepared by hospital staff for primary care teams is affected by influences from multiple domains, requiring a multifaceted approach to improve handovers. Although only based on findings from one hospital, the designed intervention should be tested in clinical settings with key stakeholders, including primary care staff, to evaluate impact on quality of written handovers and patient safety. FUNDING: National Institute for Health and Care Research (NIHR) Imperial Patient Safety Translational Research Centre.

Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System (NRLS).

BACKGROUND: Despite advances in understanding and reducing the risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify nonprocedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement. METHODS: Endoscopy-specific PSI reports were extracted from the National Reporting and Learning System (NRLS). A retrospective, cross-sectional human factors analysis of data was performed. Two independent researchers coded data using a hybrid thematic analysis approach. The Human Factors Analysis and Classification System (HFACS) was used to code contributory factors. Analysis informed creation of driver diagrams and key recommendations for safety improvement in endoscopy. RESULTS: From 2017 to 2019, 1181 endoscopy-specific PSIs of significant harm were reported across England and Wales, with 539 (45.6%) being nPSIs. Five categories accounted for over 80% of all incidents, with "follow-up and surveillance" being the largest (23.4% of all nPSIs). From the free-text incident reports, 487 human factors codes were identified. Decision-based errors were the most common act prior to PSI occurrence. Other frequent preconditions to incidents were focused on environmental factors, particularly overwhelmed resources, patient factors, and ineffective team communication. Lack of staffing, standard operating procedures, effective systems, and clinical pathways were also contributory. Seven key recommendations for improving safety have been made in response to our findings. CONCLUSIONS: This was the first national-level human factors analysis of endoscopy-specific PSIs. This work will inform safety improvement strategies and should empower individual services to review their approach to safety.

The cost of living crisis - how does it impact the health and life of individuals? A survey exploring perceptions in Italy, Germany, Sweden and the United Kingdom.

BACKGROUND: The Cost of Living Crisis (CoLC), a real term reduction in basic income, risks individuals being unable to afford essentials such as heat, food and clothing. The impact of the CoLC is disproportionate - with different population sub-groups more likely to be negatively affected. The objective of this survey was to evaluate the perceived impact of the CoLC on the life and health of participants across four European countries. METHODS: A survey housing two questions to investigate the relationship between the CoLC and its perceived impact on life and health was developed. Four European countries (U.K., Sweden, Italy and Germany) took part via the YouGov platform. Logistic regression models were created for each country and question to evaluate which population characteristics were associated with a negative reported impact of the CoLC. RESULTS: A total of 8,152 unique individuals responded between 17th March and 30th March 2023. Each country was equally represented. Those aged 36-64 were more likely to report a negative impact of the CoLC on their life and health than younger participants (p < 0.001, p = 0.02 respectively). Across all countries, females were significantly more likely to report a negative impact on their life and health, however, when analysed according to country, in Sweden females were less likely to report a negative impact (p < 0.001). Those in lower income families or who reported poor health in the preceding 12 months were significantly more likely to report a negative impact of the CoLC on their life and health. There was no difference within the participant group on the reported impact of the CoLC based on location (rural vs. urban). CONCLUSIONS: We demonstrate the disproportionate negative impact of the CoLC on both life and health in different population subgroups. Germany and Sweden appeared to be more resilient to the effects of the CoLC, particularly for certain population subgroups. It is important to understand the differing effects of a CoLC, and to learn from successful health and economic strategies in order to create targeted policy and create a population resilient to economic shocks.

Identifying barriers to outpatient appointment attendance in patient groups at risk of inequity: a mixed methods study in a London NHS trust.

BACKGROUND: There is significant health inequity in the United Kingdom (U.K.), with different populations facing challenges accessing health services, which can impact health outcomes. At one London National Health Service (NHS) Trust, data showed that patients from deprived areas and minority ethnic groups had a higher likelihood of missing their first outpatient appointment. This study's objectives were to understand barriers to specific patient populations attending first outpatient appointments, explore systemic factors and assess appointment awareness. METHODS: Five high-volume specialties identified as having inequitable access based on ethnicity and deprivation were selected as the study setting. Mixed methods were employed to understand barriers to outpatient attendance, including qualitative semi-structured interviews with patients and staff, observations of staff workflows and interrogation of quantitative data on appointment communication. To identify barriers, semi-structured interviews were conducted with patients who missed their appointment and were from a minority ethnic group or deprived area. Staff interviews and observations were carried out to further understand attendance barriers. Patient interview data were analysed using inductive thematic analysis to create a thematic framework and triangulated with staff data. Subthemes were mapped onto a behavioural science framework highlighting behaviours that could be targeted. Quantitative data from patient interviews were analysed to assess appointment awareness and communication. RESULTS: Twenty-six patients and 11 staff were interviewed, with four staff observed. Seven themes were identified as barriers - communication factors, communication methods, healthcare system, system errors, transport, appointment, and personal factors. Knowledge about appointments was an important identified behaviour, supported by eight out of 26 patients answering that they were unaware of their missed appointment. Environmental context and resources were other strongly represented behavioural factors, highlighting systemic barriers that prevent attendance. CONCLUSION: This study showed the barriers preventing patients from minority ethnic groups or living in deprived areas from attending their outpatient appointment. These barriers included communication factors, communication methods, healthcare the system, system errors, transport, appointment, and personal factors. Healthcare services should acknowledge this and work with public members from these communities to co-design solutions supporting attendance. Our work provides a basis for future intervention design, informed by behavioural science and community involvement.

Validity of Self-testing at Home With Rapid Severe Acute Respiratory Syndrome Coronavirus 2 Antibody Detection by Lateral Flow Immunoassay.

BACKGROUND: We explore severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody lateral flow immunoassay (LFIA) performance under field conditions compared to laboratory-based electrochemiluminescence immunoassay (ECLIA) and live virus neutralization. METHODS: In July 2021, 3758 participants performed, at home, a self-administered Fortress LFIA on finger-prick blood, reported and submitted a photograph of the result, and provided a self-collected capillary blood sample for assessment of immunoglobulin G (IgG) antibodies using the Roche Elecsys® Anti-SARS-CoV-2 ECLIA. We compared the self-reported LFIA result to the quantitative ECLIA and checked the reading of the LFIA result with an automated image analysis (ALFA). In a subsample of 250 participants, we compared the results to live virus neutralization. RESULTS: Almost all participants (3593/3758, 95.6%) had been vaccinated or reported prior infection. Overall, 2777/3758 (73.9%) were positive on self-reported LFIA, 2811/3457 (81.3%) positive by LFIA when ALFA-reported, and 3622/3758 (96.4%) positive on ECLIA (using the manufacturer reference standard threshold for positivity of 0.8 U mL-1). Live virus neutralization was detected in 169 of 250 randomly selected samples (67.6%); 133/169 were positive with self-reported LFIA (sensitivity 78.7%; 95% confidence interval [CI]: 71.8, 84.6), 142/155 (91.6%; 95% CI: 86.1, 95.5) with ALFA, and 169 (100%; 95% CI: 97.8, 100.0) with ECLIA. There were 81 samples with no detectable virus neutralization; 47/81 were negative with self-reported LFIA (specificity 58.0%; 95% CI: 46.5, 68.9), 34/75 (45.3%; 95% CI: 33.8, 57.3) with ALFA, and 0/81 (0%; 95% CI: 0, 4.5) with ECLIA. CONCLUSIONS: Self-administered LFIA is less sensitive than a quantitative antibody test, but the positivity in LFIA correlates better than the quantitative ECLIA with virus neutralization.

Impact of Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy on Upper Limb Morbidity in Breast Cancer Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the impact of axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) on upper limb (UL) morbidity in breast cancer patients. BACKGROUND: Axillary de-escalation is motivated by a desire to reduce harm of ALND. Understanding the impact of axillary surgery and disparities in operative procedures on postoperative arm morbidity would better direct resources to the point of need and cement the need for de-escalation strategies. METHODS: Embase, MEDLINE, CINAHL, and PsychINFO were searched from 1990 until March 2020. Included studies were randomized-controlled and observational studies focusing on UL morbidities, in breast surgery patients. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of UL morbidity comparing SLNB and ALND at <12 months, 12 to 24 months, and beyond 24 months were analyzed. RESULTS: Sixty-seven studies were included. All studies reported a higher rate of lymphedema and pain after ALND compared with SLNB. The difference in lymphedema and pain prevalence between SLNB and ALND was 13.7% (95% confidence interval: 10.5-16.8, P <0.005) and 24.2% (95% confidence interval: 12.1-36.3, P <0.005), respectively. Pooled estimates for prevalence of reduced strength and range of motion after SLNB and ALND were 15.2% versus 30.9% and 17.1% versus 29.8%, respectively. Type of axillary surgery, greater body mass index, and radiotherapy were some of the predictors for UL morbidities. CONCLUSIONS: Prevalence of lymphedema after ALND was higher than previously estimated. ALND patients experienced greater rates of lymphedema, pain, reduced strength, and range of motion compared with SLNB. The findings support the continued drive to de-escalate axillary surgery.

Lipidomic Profiling of Colorectal Lesions for Real-Time Tissue Recognition and Risk-Stratification Using Rapid Evaporative Ionization Mass Spectrometry.

OBJECTIVE: Rapid evaporative ionization mass spectrometry (REIMS) is a metabolomic technique analyzing tissue metabolites, which can be applied intraoperatively in real-time. The objective of this study was to profile the lipid composition of colorectal tissues using REIMS, assessing its accuracy for real-time tissue recognition and risk-stratification. SUMMARY BACKGROUND DATA: Metabolic dysregulation is a hallmark feature of carcinogenesis; however, it remains unknown if this can be leveraged for real-time clinical applications in colorectal disease. METHODS: Patients undergoing colorectal resection were included, with carcinoma, adenoma and paired-normal mucosa sampled. Ex vivo analysis with REIMS was conducted using monopolar diathermy, with the aerosol aspirated into a Xevo G2S QToF mass spectrometer. Negatively charged ions over 600 to 1000 m/z were used for univariate and multivariate functions including linear discriminant analysis. RESULTS: A total of 161 patients were included, generating 1013 spectra. Unique lipidomic profiles exist for each tissue type, with REIMS differentiating samples of carcinoma, adenoma, and normal mucosa with 93.1% accuracy and 96.1% negative predictive value for carcinoma. Neoplasia (carcinoma or adenoma) could be predicted with 96.0% accuracy and 91.8% negative predictive value. Adenomas can be risk-stratified by grade of dysplasia with 93.5% accuracy, but not histological subtype. The structure of 61 lipid metabolites was identified, revealing that during colorectal carcinogenesis there is progressive increase in relative abundance of phosphatidylglycerols, sphingomyelins, and mono-unsaturated fatty acid-containing phospholipids. CONCLUSIONS: The colorectal lipidome can be sampled by REIMS and leveraged for accurate real-time tissue recognition, in addition to riskstratification of colorectal adenomas. Unique lipidomic features associated with carcinogenesis are described.

Implementing behavioural science informed letter interventions to increase COVID-19 vaccination uptake in uncontactable London residents: a difference-in-difference study in London, UK.

BACKGROUND: The UK COVID-19 vaccination programme began in December, 2020. By February, 2021, eight North West London Clinical Commissioning Groups (CCGs) had the lowest vaccination rates nationally. This study evaluated the impact of behavioural science-informed (BI) letters on vaccination uptake. METHODS: Unvaccinated residents of the Central London CCG who were deemed uncontactable (through text messaging and phone calls) were identified with the whole systems integrated care database. BI letters were sent to residents in the intervention CCG between May and June, 2021. Three neighbouring CCGs in London with similar non-responder data were used as control groups. A linear difference-in-difference analysis was undertaken to assess change in vaccine uptake rate across all four CCGs. Percentage point change was adjusted for selected covariates including ethnicity, age, gender, and index of multiple deprivation (IMD) quintiles. Approval was obtained from the quality improvement and audit office of Imperial College Healthcare NHS Trust (London, UK). FINDINGS: Within the intervention Central London CCG, 10 161 residents received the BI letter. The control CCGs contained 27 383 uncontactable residents. All CCGs showed an increase in vaccination rates in this population. The linear difference-in-difference analysis showed an increase in vaccination uptake in the intervention CCG (relative change 31·9% (95% CI 30·5-33·3; p<0·0001). Residents in IMD quintile 5 (least deprived) showed the largest rate of change (4·1%; p<0·0001). Residents with a mixed or multiple ethnic background were less likely to receive a COVID-19 vaccine (-4·1%, p<0·0001). INTERPRETATION: BI letters improved the rate of vaccine uptake. The percentage point increase of 31·9% equates to 436 additional previously uncontactable residents being vaccinated. Our data highlighted differences in the effect of BI-informed interventions in population subgroups. BI letters are a cost-effective and trusted communication tool, effectively engaging residents where other communication strategies did not work. FUNDING: None.

The Use of Wearable Activity Monitors to Measure Upper Limb Physical Activity After Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy.

BACKGROUND: We suspect that morbidity from both sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) has been inadequately evaluated to date. Current methodologies are subjective and susceptible to bias. Objective assessment using wearable activity monitors (WAMs) would allow quantitative analysis of recovery by measuring physical activity (PA) and could provide evidence for axillary de-escalation. PATIENTS AND METHODS: A prospective, single center, observational study was conducted from February 2020 to May 2022. Consecutive patients undergoing breast and/or reconstructive surgery and axillary surgeries were identified from the operating schedules. Patients wore WAMs for an average of 3 days prior to surgery and up to 2 weeks following surgery. In total, 56 patients with breast cancer were recruited, of whom 35 underwent SLNB and 21 ALND. RESULTS: Patients who underwent ALND experienced significantly worse PA compared with those who underwent SLNB in week 2 (median 66.4% versus 72.7%, p = 0.015). Subgroup analysis revealed significantly lower PA in simple mastectomy (Mx)-ALND versus Mx-SLNB (median 90.3% versus 70.5%, p = 0.015) in week 2. The PA for SLNB did not return to baseline at 2 weeks after surgery. CONCLUSIONS: Compared with SLNB, ALND results in a lower PA level in week 2. The findings also indicate that SLNB has a protracted effect on PA levels, which extend to 2 weeks postoperatively. Monitoring recovery objectively following breast cancer surgery provides patients and surgeons with more information regarding the predicted outcomes of their surgery, which can drive the development of a personalized rehabilitation program.

Development of the "Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills" (TEAM-ENTS) behavioral marker system.

BACKGROUND: Non-technical skills (NTS) are integral to team performance and subsequent quality and safety of care. Behavioral marker systems (BMSs) are now increasingly used in healthcare to support the training and assessment of team NTS. Within gastrointestinal endoscopy, this is an area of novel research. The aims of this study were to define the core relevant NTS for endoscopy teams and develop a preliminary framework for a team-based BMS known as TEAM-ENTS (Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills). METHODS: This study was conducted in two phases. In phase 1, a literature review of team-based BMSs was performed to inform an interview study of core endoscopy team members. Cognitive task analysis was used to break down the NTS relevant to endoscopy teams. Framework analysis generated the structure for the preliminary TEAM-ENTS framework. In phase 2, a modified Delphi process was undertaken to refine the items of the framework. RESULTS: Seven consultant endoscopists and six nurses were interviewed. The final coding framework consisted of 88 codes grouped into five overarching categories. In total, 58 participants were recruited to the Delphi panel. In the first round, nine elements and 37 behavioral descriptors did not meet consensus. Following item adjustment, merging and deletion, all remaining items met consensus thresholds after the second round. The refined TEAM-ENTS BMS consists of five categories, 16 elements, and 47 behavioral descriptors. CONCLUSIONS: The refined TEAM-ENTS behavioral marker system was developed to reflect the core NTS relevant to endoscopy teams. Future studies will aim to fully validate this tool.

Design and Implementation of a National Program to Monitor the Prevalence of SARS-CoV-2 IgG Antibodies in England Using Self-Testing: The REACT-2 Study.

Data System. The UK Department of Health and Social Care funded the REal-time Assessment of Community Transmission-2 (REACT-2) study to estimate community prevalence of SARS-CoV-2 IgG (immunoglobulin G) antibodies in England. Data Collection/Processing. We obtained random cross-sectional samples of adults from the National Health Service (NHS) patient list (near-universal coverage). We sent participants a lateral flow immunoassay (LFIA) self-test, and they reported the result online. Overall, 905 991 tests were performed (28.9% response) over 6 rounds of data collection (June 2020-May 2021). Data Analysis/Dissemination. We produced weighted estimates of LFIA test positivity (validated against neutralizing antibodies), adjusted for test performance, at local, regional, and national levels and by age, sex, and ethnic group and area-level deprivation score. In each round, fieldwork occurred over 2 weeks, with results reported to policymakers the following week. We disseminated results as preprints and peer-reviewed journal publications. Public Health Implications. REACT-2 estimated the scale and variation in antibody prevalence over time. Community self-testing and -reporting produced rapid insights into the changing course of the pandemic and the impact of vaccine rollout, with implications for future surveillance. (Am J Public Health. 2023;113(11):1201-1209. https://doi.org/10.2105/AJPH.2023.307381).

Design and Implementation of a National SARS-CoV-2 Monitoring Program in England: REACT-1 Study.

Data System. The REal-time Assessment of Community Transmission-1 (REACT-1) Study was funded by the Department of Health and Social Care in England to provide reliable and timely estimates of prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection over time, by person and place. Data Collection/Processing. The study team (researchers from Imperial College London and its logistics partner Ipsos) wrote to named individuals aged 5 years and older in random cross-sections of the population of England, using the National Health Service list of patients registered with a general practitioner (near-universal coverage) as a sampling frame. We collected data over 2 to 3 weeks approximately every month across 19 rounds of data collection from May 1, 2020, to March 31, 2022. Data Analysis/Dissemination. We have disseminated the data and study materials widely via the study Web site, preprints, publications in peer-reviewed journals, and the media. We make available data tabulations, suitably anonymized to protect participant confidentiality, on request to the study's data access committee. Public Health Implications. The study provided inter alia real-time data on SARS-CoV-2 prevalence over time, by area, and by sociodemographic variables; estimates of vaccine effectiveness; and symptom profiles, and detected emergence of new variants based on viral genome sequencing. (Am J Public Health. 2023;113(5):545-554. https://doi.org/10.2105/AJPH.2023.307230).

Trends in SARS-CoV-2 infection prevalence during England's roadmap out of lockdown, January to July 2021.

BACKGROUND: Following rapidly rising COVID-19 case numbers, England entered a national lockdown on 6 January 2021, with staged relaxations of restrictions from 8 March 2021 onwards. AIM: We characterise how the lockdown and subsequent easing of restrictions affected trends in SARS-CoV-2 infection prevalence. METHODS: On average, risk of infection is proportional to infection prevalence. The REal-time Assessment of Community Transmission-1 (REACT-1) study is a repeat cross-sectional study of over 98,000 people every round (rounds approximately monthly) that estimates infection prevalence in England. We used Bayesian P-splines to estimate prevalence and the time-varying reproduction number (Rt) nationally, regionally and by age group from round 8 (beginning 6 January 2021) to round 13 (ending 12 July 2021) of REACT-1. As a comparator, a separate segmented-exponential model was used to quantify the impact on Rt of each relaxation of restrictions. RESULTS: Following an initial plateau of 1.54% until mid-January, infection prevalence decreased until 13 May when it reached a minimum of 0.09%, before increasing until the end of the study to 0.76%. Following the first easing of restrictions, which included schools reopening, the reproduction number Rt increased by 82% (55%, 108%), but then decreased by 61% (82%, 53%) at the second easing of restrictions, which was timed to match the Easter school holidays. Following further relaxations of restrictions, the observed Rt increased steadily, though the increase due to these restrictions being relaxed was offset by the effects of vaccination and also affected by the rapid rise of Delta. There was a high degree of synchrony in the temporal patterns of prevalence between regions and age groups. CONCLUSION: High-resolution prevalence data fitted to P-splines allowed us to show that the lockdown was effective at reducing risk of infection with school holidays/closures playing a significant part.

Population health: transformation will happen at the speed of trust.

The societal shocks at the beginning of the 2020s have yet again brought into focus fundamental issues of inequality and distrust. These two corrosive and inter-related factors are the root cause of what inhibits our progress on issues such as improving population health and sustainable healthcare. Based on evidence, the authors provide their perspective to suggests three policy proposals; create a new power social movement for better health and equality; delegation of `old power' to City Mayors; handing over power and privilege to communities. This is the only way we will break the cycle of decreasing trust and increasing inequality and build a happier, healthier, and more resilient society.

Healthy city: global systematic scoping review of city initiatives to improve health with policy recommendations.

BACKGROUND: Global health will increasingly be determined by cities. Currently over half of the world's population, over 4 billion people, live in cities. This systematic scoping review has been conducted to understand what cities are doing to improve health and healthcare for their populations. METHODS: We conducted a systematic search to identify literature on city-wide initiatives to improve health. The study was conducted in accordance with PRISMA and the protocol was registered with PROSPERO (CRD42020166210). RESULTS: The search identified 42,137 original citations, yielding 1,614 papers across 227 cities meeting the inclusion criteria. The results show that the majority of initiatives were targeted at non-communicable diseases. City health departments are making an increasing contribution; however the role of mayors appears to be limited. CONCLUSION: The collective body of evidence identified in this review, built up over the last 130 years, has hitherto been poorly documented and characterised. Cities are a meta-system with population health dictated by multiple interactions and multidirectional feedback loops. Improving health in cities requires multiple actions, by multiple actors, at every level. The authors use the term 'The Vital 5'. They are the five most important health risk factors; tobacco use; harmful alcohol use; physical-inactivity, unhealthy diet and planetary health. These 'Vital 5' are most concentrated in deprived areas and show the greatest increase in low and middle income countries. Every city should develop a comprehensive strategy and action plan to address these 'Vital 5'.

Perceptions of chief clinical information officers on the state of electronic health records systems interoperability in NHS England: a qualitative interview study.

BACKGROUND: In the era of electronic health records (EHR), the ability to share clinical data is a key facilitator of healthcare delivery. Since the introduction of EHRs, this aspect has been extensively studied from the perspective of healthcare providers. Less often explored are the day-to-day challenges surrounding the procurement, deployment, maintenance, and use of interoperable EHR systems, from the perspective of healthcare administrators, such as chief clinical information officers (CCIOs). OBJECTIVE: Our study aims to capture the perceptions of CCIOs on the current state of EHR interoperability in the NHS, its impact on patient safety, the perceived facilitators and barriers to improving EHR interoperability, and what the future of EHR development in the NHS may entail. METHODS: Semi-structured interviews were conducted between November 2020 - October 2021. Convenience sampling was employed to recruit NHS England CCIOs. Interviews were digitally recorded and transcribed verbatim. A thematic analysis was performed by two independent researchers to identify emerging themes. RESULTS: Fifteen CCIOs participated in the study. Participants reported that limited EHR interoperability contributed to the inability to easily access and transfer data into a unified source, thus resulting in data fragmentation. The resulting lack of clarity on patients' health status negatively impacts patient safety through suboptimal care coordination, duplication of efforts, and more defensive practice. Facilitators to improving interoperability included the recognition of the need by clinicians, patient expectations, and the inherent centralised nature of the NHS. Barriers included systems usability difficulties, and institutional, data management, and financial-related challenges. Looking ahead, participants acknowledged that realising that vision across the NHS would require a renewed focus on mandating data standards, user-centred design, greater patient involvement, and encouraging inter-organisational collaboration. CONCLUSION: Tackling poor interoperability will require solutions both at the technical level and in the wider policy context. This will involve demanding interoperability functionalities from the outset in procurement contracts, fostering greater inter-organisation cooperation on implementation strategies, and encouraging systems vendors to prioritise interoperability in their products. Only by comprehensively addressing these challenges would the full potential promised by the use of fully interoperable EHRs be realised.