Reconsidering the relationship between health and income in the UK.

The present paper revisits and extends the examination of the long-run relationship between UK life expectancy and income provided by Tapia Granados (2012). Adopting a more detailed form of analysis, a clear break corresponding to the 1918-1919 Influenza Pandemic is identified in the long span of data examined. This finding of structural change, along with detected uncertainty regarding the orders of integration of the series examined, results in the application of split-sample analysis employing autoregressive distributed lag (ARDL) modelling. The results obtained reverse the 'no long-run relationship' conclusion of Tapia Granados (2012) with overwhelming evidence presented in support of a negative relationship between life expectancy and income. Our findings add to both health-income research and a burgeoning literature on the reproduction and replication of previously published empirical research.

Rapid resolution of severe sustained low blood pressure in haemodialysis patients after successful renal transplantation.

BACKGROUND: Low blood pressure occurring in the absence of volume depletion, anti-hypertensive medication, heart failure or cortisol deficiency occurs in ~5-10% of haemodialysis patients, and can result in serious complications. The pathophysiology of this syndrome is poorly understood. METHODS: We describe eight cases with dialysis-associated hypotension who underwent renal transplantation. Four patients were severely hypotensive with a systolic blood pressure (SBP) <100 mmHg before and during dialysis, and four had a SBP usually <100 mmHg during dialysis, but usually >100 mmHg between sessions. All had donor-specific human leukocyte antigen antibodies. Six patients underwent pre-transplant plasmapheresis, which was curtailed in two because of further falls in blood pressure. Two patients experienced clotting of their arteriovenous fistula. In one patient cryofiltration was used, which was tolerated without severe falls in the BP. The remaining patient, who had hypotension-associated retinal vein thrombosis before transplant, was supported with an epinephrine infusion and did not receive plasmapheresis. RESULTS: Post-transplant, the first patient did not receive pressor therapy and died from bowel ischaemia. The other seven patients were supported with inotropes on critical care. The administration of steroids did not reverse hypotension. The mean pre-treatment SBP was 96 mmHg (range 71-110, SEM 5.0). After inotropes were withdrawn and graft function was established, the mean SBP was 127 mmHg (range 113-149, SEM 4.9) (P < 0.01). CONCLUSIONS: Renal transplantation was performed successfully and safely in patients when pressor therapy was used to treat severe dialysis-associated hypotension and, moreover, the blood pressure normalized rapidly after graft function was established.

Efficacy of a combined insecticide-rodenticide product on ectoparasite and commensal rodent mortality.

BACKGROUND: Ectoparasites may transfer zoonotic pathogens from rodents to humans or livestock when rodents are managed with rodenticides. This could be minimized using a product combining a rodenticide with a delayed action and a systemic insecticide/acaricide that rapidly kills ectoparasites. Such a combination was tested in commensal pest rodent species to assess efficacy and timing of responses in rodents, and fleas and ticks feeding on them. Ticks or fleas attached to rats (Rattus norvegicus) and house mice (Mus musculus domesticus) were exposed to a product containing brodifacoum (50 ppm) and fipronil (40 ppm) for three days. RESULTS: 98-100% of fleas on treated rodents died within one to two days after first exposure, whereas >90% fleas survived on control rodents. The effect persisted for four or more days after bait uptake. Ticks started to succumb to the effect of the combination product within one day (mice) and within four days (rats) of first exposure, with all ticks dying by Day (D)8. Tick survival in control rodents was 90-100%. Rodent mortality began at D3 (rats) and D4 (mice) after first consumption of product and all were dead by D9 (rats) and D7 (mice). CONCLUSION: This product effectively killed ectoparasites and rodents. Flea mortality was swift and complete, generally within one day of exposure, whereas it took ticks up to four days to die, but before the rats and house mice died. The combination product might help to prevent ectoparasites migrating from dying rodents to another host. Field trials are warranted. © 2020 Society of Chemical Industry.

Impact of introducing an electronic physiological surveillance system on hospital mortality.

BACKGROUND: Avoidable hospital mortality is often attributable to inadequate patient vital signs monitoring, and failure to recognise or respond to clinical deterioration. The processes involved with vital sign collection and charting; their integration, interpretation and analysis; and the delivery of decision support regarding subsequent clinical care are subject to potential error and/or failure. OBJECTIVE: To determine whether introducing an electronic physiological surveillance system (EPSS), specifically designed to improve the collection and clinical use of vital signs data, reduced hospital mortality. METHODS: A pragmatic, retrospective, observational study of seasonally adjusted in-hospital mortality rates in three main hospital specialties was undertaken before, during and after the sequential deployment and ongoing use of a hospital-wide EPSS in two large unconnected acute general hospitals in England. The EPSS, which uses wireless handheld computing devices, replaced a paper-based vital sign charting and clinical escalation system. RESULTS: During EPSS implementation, crude mortality fell from a baseline of 7.75% (2168/27,959) to 6.42% (1904/29,676) in one hospital (estimated 397 fewer deaths), and from 7.57% (1648/21,771) to 6.15% (1614/26,241) at the second (estimated 372 fewer deaths). At both hospitals, multiyear statistical process control analyses revealed abrupt and sustained mortality reductions, coincident with the deployment and increasing use of the system. The cumulative total of excess deaths reduced in all specialties with increasing use of the system across the hospital. CONCLUSIONS: The use of technology specifically designed to improve the accuracy, reliability and availability of patients' vital signs and early warning scores, and thereby the recognition of and response to patient deterioration, is associated with reduced mortality in this study.

Index blood tests and national early warning scores within 24 hours of emergency admission can predict the risk of in-hospital mortality: a model development and validation study.

BACKGROUND: We explored the use of routine blood tests and national early warning scores (NEWS) reported within ±24 hours of admission to predict in-hospital mortality in emergency admissions, using empirical decision Tree models because they are intuitive and may ultimately be used to support clinical decision making. METHODOLOGY: A retrospective analysis of adult emergency admissions to a large acute hospital during April 2009 to March 2010 in the West Midlands, England, with a full set of index blood tests results (albumin, creatinine, haemoglobin, potassium, sodium, urea, white cell count and an index NEWS undertaken within ±24 hours of admission). We developed a Tree model by randomly splitting the admissions into a training (50%) and validation dataset (50%) and assessed its accuracy using the concordance (c-) statistic. Emergency admissions (about 30%) did not have a full set of index blood tests and/or NEWS and so were not included in our analysis. RESULTS: There were 23248 emergency admissions with a full set of blood tests and NEWS with an in-hospital mortality of 5.69%. The Tree model identified age, NEWS, albumin, sodium, white cell count and urea as significant (p<0.001) predictors of death, which described 17 homogeneous subgroups of admissions with mortality ranging from 0.2% to 60%. The c-statistic for the training model was 0.864 (95%CI 0.852 to 0.87) and when applied to the testing data set this was 0.853 (95%CI 0.840 to 0.866). CONCLUSIONS: An easy to interpret validated risk adjustment Tree model using blood test and NEWS taken within ±24 hours of admission provides good discrimination and offers a novel approach to risk adjustment which may potentially support clinical decision making. Given the nature of the clinical data, the results are likely to be generalisable but further research is required to investigate this promising approach.

Risk stratification by pre-operative cardiopulmonary exercise testing improves outcomes following elective abdominal aortic aneurysm surgery: a cohort study.

BACKGROUND: In 2009, the NHS evidence adoption center and National Institute for Health and Care Excellence (NICE) published a review of the use of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). They recommended the development of a risk-assessment tool to help identify AAA patients with greater or lesser risk of operative mortality and to contribute to mortality prediction.A low anaerobic threshold (AT), which is a reliable, objective measure of pre-operative cardiorespiratory fitness, as determined by pre-operative cardiopulmonary exercise testing (CPET) is associated with poor surgical outcomes for major abdominal surgery. We aimed to assess the impact of a CPET-based risk-stratification strategy upon perioperative mortality, length of stay and non-operative costs for elective (open and endovascular) infra-renal AAA patients. METHODS: A retrospective cohort study was undertaken. Pre-operative CPET-based selection for elective surgical intervention was introduced in 2007. An anonymized cohort of 230 consecutive infra-renal AAA patients (2007 to 2011) was studied. A historical control group of 128 consecutive infra-renal AAA patients (2003 to 2007) was identified for comparison.Comparative analysis of demographic and outcome data for CPET-pass (AT ≥ 11 ml/kg/min), CPET-fail (AT < 11 ml/kg/min) and CPET-submaximal (no AT generated) subgroups with control subjects was performed. Primary outcomes included 30-day mortality, survival and length of stay (LOS); secondary outcomes were non-operative inpatient costs. RESULTS: Of 230 subjects, 188 underwent CPET: CPET-pass n = 131, CPET-fail n = 35 and CPET-submaximal n = 22. When compared to the controls, CPET-pass patients exhibited reduced median total LOS (10 vs 13 days for open surgery, n = 74, P < 0.01 and 4 vs 6 days for EVAR, n = 29, P < 0.05), intensive therapy unit requirement (3 vs 4 days for open repair only, P < 0.001), non-operative costs (£5,387 vs £9,634 for open repair, P < 0.001) and perioperative mortality (2.7% vs 12.6% (odds ratio: 0.19) for open repair only, P < 0.05). CPET-stratified (open/endovascular) patients exhibited a mid-term survival benefit (P < 0.05). CONCLUSION: In this retrospective cohort study, a pre-operative AT > 11 ml/kg/min was associated with reduced perioperative mortality (open cases only), LOS, survival and inpatient costs (open and endovascular repair) for elective infra-renal AAA surgery.

S(p)O(2) values in acute medical admissions breathing air--implications for the British Thoracic Society guideline for emergency oxygen use in adult patients?

S(p)O(2) is routinely used to assess the well-being of patients, but it is difficult to find an evidence-based description of its normal range. The British Thoracic Society (BTS) has published guidance for oxygen administration and recommends a target S(p)O(2) of 94-98% for most adult patients. These recommendations rely on consensus opinion and small studies using arterial blood gas measurements of saturation (S(a)O(2)). Using large datasets of routinely collected vital signs from four hospitals, we analysed the S(p)O(2) range of 37,593 acute general medical inpatients (males: 47%) observed to be breathing room air. Age at admission ranged from 16 to 105 years with a mean (SD) of 64 (21) years. 19,642 admissions (52%) were aged <70 years. S(p)O(2) ranged from 70% to 100% with a median (IQR) of 97% (95-98%). S(p)O(2) values for males and females were similar. In-hospital mortality for the study patients was 5.27% (range 4.80-6.27%). Mortality (95% CI) for patients with initial S(p)O(2) values of 97%, 96% and 95% was 3.65% (3.22-4.13); 4.47% (3.99-5.00); and 5.67% (5.03-6.38), respectively. Additional analyses of S(p)O(2) values for 37,299 medical admissions aged ≥18 years provided results that were distinctly different to those upon which the current BTS guidelines based their definition of normality. Our findings suggest that the BTS should consider changing its target saturation for actively treated patients not at risk of hypercapnic respiratory failure to 96-98%.