The impact of changes in coding on mortality reports using the example of sepsis.

OBJECTIVES: NHS Digital issued new guidance on sepsis coding in April 2017 which was further modified in April 2018. During these timeframes some centres reported increased sepsis associated mortality, whilst others reported reduced mortality, in some cases coincident with specific quality improvement programmes. We hypothesised that changes in reported mortality could not be separated from changes in coding practice. METHODS: Hospital Episode Statistics from the Admitted Patient Care dataset for NHS hospitals in England, from April 2016 to March 2020 were analysed. Admissions of adults with sepsis: an International Classification of Diseases 10 (ICD-10) code associated with the Agency for Healthcare Research and Quality Clinical Classifications Software class 'Septicaemia (except in labour)', were assessed. Patient comorbidities were defined by other ICD-10 codes recorded within the admission episode. RESULTS: 1,081,565 hospital episodes with a coded diagnosis of sepsis were studied. After April 2017 there was a significant increase in admission episodes with sepsis coded as the primary reason for admission. There were significant changes in the case-mix of patients with a primary diagnosis of sepsis after April 2017. An analysis of case-mix, hospital and year treated as random effects, defined a small reduction in sepsis associated mortality across England following the first change in coding guidance. No centre specific improvement in outcome could be separated from these random-effects. CONCLUSION: Changes in sepsis coding practice altered case-mix and case selection, in ways that varied between centres. This was associated with changes in centre-specific sepsis associated mortality, over time. According to the direction of change these may be interpreted either as requiring local investigation for cause or as supporting coincident changes in clinical practice. A whole system analysis showed that centre specific changes in mortality cannot be separated from system-wide changes. Caution is therefore required when interpreting sepsis outcomes in England, particularly when using single centre studies to inform or support guidance or policy.

Early renal function trajectories, cytomegalovirus serostatus and long-term graft outcomes in kidney transplant recipients.

BACKGROUND: Improved recognition of factors influencing graft survival has led to better short-term kidney transplant outcomes. However, efforts to prevent long-term graft decline and improve graft survival have seen more modest improvements. The adoption of electronic health records has enabled better recording and identification of donor-recipient factors through the use of modern statistical techniques. We have previously shown in a prevalent renal transplant population that episodes of rapid deterioration are associated with graft loss. METHODS: Estimated glomerular filtration rates (eGFR) between 3 and 27 months after transplantation were collected from 310 kidney transplant recipients. We utilised a Bayesian approach to estimate the most likely eGFR trajectory as a smooth curve from an average of 10,000 Monte Carlo samples. The probability of having an episode of rapid deterioration (decline greater than 5 ml/min/1.73 m2 per year in any 1-month period) was calculated. Graft loss and mortality data was collected over a median follow-up period of 8 years. Factors associated with having an episode of rapid deterioration and associations with long-term graft loss were explored. RESULTS: In multivariable Cox Proportional Hazard analysis, a probability greater than 0.8 of rapid deterioration was associated with long-term death-censored graft loss (Hazard ratio 2.17; 95% Confidence intervals [CI] 1.04-4.55). In separate multivariable logistic regression models, cytomegalovirus (CMV) serostatus donor positive to recipient positive (Odds ratio [OR] 3.82; 95%CI 1.63-8.97), CMV donor positive (OR 2.06; 95%CI 1.15-3.68), and CMV recipient positive (OR 2.03; 95%CI 1.14-3.60) were associated with having a greater than 0.8 probability of an episode of rapid deterioration. CONCLUSIONS: Early episodes of rapid deterioration are associated with long-term death-censored graft loss and are associated with cytomegalovirus seropositivity. Further study is required to better manage these potentially modifiable risks factors and improve long-term graft survival.

Germanium tin alloy nanowires as anode materials for high performance Li-ion batteries.

The combination of two active Li-ion materials (Ge and Sn) can result in improved conduction paths and higher capacity retention. Here we report for the first time, the implementation of Ge1-x Sn x alloy nanowires as anode materials for Li-ion batteries. Ge1-x Sn x alloy nanowires have been successfully grown via vapor-liquid-solid technique directly on stainless steel current collectors. Ge1-x Sn x (x = 0.048) nanowires were predominantly seeded from the Au0.80Ag0.20 catalysts with negligible amount of growth was also directly catalyzed from stainless steel substrate. The electrochemical performance of the the Ge1-x Sn x nanowires as an anode material for Li-ion batteries was investigated via galvanostatic cycling and detailed analysis of differential capacity plots (DCPs). The nanowire electrodes demonstrated an exceptional capacity retention of 93.4% from the 2nd to the 100th charge at a C/5 rate, while maintaining a specific capacity value of ∼921 mAh g-1 after 100 cycles. Voltage profiles and DCPs revealed that the Ge1-x Sn x nanowires behave as an alloying mode anode material, as reduction/oxidation peaks for both Ge and Sn were observed, however it is clear that the reversible lithiation of Ge is responsible for the majority of the charge stored.

Mental health in hospital emergency departments: cross-sectional analysis of attendances in England 2013/2014.

OBJECTIVE: To describe the population of patients who attend emergency departments (ED) in England for mental health reasons. METHODS: Cross-sectional observational study of 6 262 602 ED attendances at NHS (National Health Service) hospitals in England between 1 April 2013 and 31 March 2014. We assessed the proportion of attendances due to psychiatric conditions. We compared patient sociodemographic and attendance characteristics for mental health and non-mental health attendances using logistic regression. RESULTS: 4.2% of ED attendances were attributable to mental health conditions (median 3.2%, IQR 2.6% to 4.1%). Those attending for mental health reasons were typically younger (76.3% were aged less than 50 years), of White British ethnicity (73.2% White British), and resident in more deprived areas (59.9% from the two most deprived Index of Multiple Deprivation quintiles (4 and 5)). Mental health attendances were more likely to occur 'out of hours' (68.0%) and at the weekend (31.3%). Almost two-thirds were brought in by ambulance. A third required admission, but around a half were discharged home. CONCLUSIONS: This is the first national study of mental health attendances at EDs in England. We provide information for those planning and providing care, to ensure that clinical resources meet the needs of this patient group, who comprise 4.2% of attendances. In particular, we highlight the need to strengthen the availability of hospital and community care 'out of hours.'

Diagnostic uncertainty and urinary tract infection in the emergency department: a cohort study from a UK hospital.

BACKGROUND: Suspected urinary tract infection (UTI) syndromes are a common reason for empirical antibiotics to be prescribed in the Emergency Department (ED), but differentiating UTI from other conditions with a similar presentation is challenging. We investigated how often an ED diagnosis of UTI is confirmed clinically/microbiologically, and described conditions which present as UTI syndromes. METHODS: Observational study using electronic health records from patients who attended the ED with suspected UTI and had a urine sample submitted for culture. We compared the ED diagnosis to diagnosis at discharge from hospital (ICD-10 codes), and estimated the proportion of cases with clinical/microbiological evidence of UTI. RESULTS: Two hundred eighty nine patients had an ED diagnosis of UTI syndrome comprising: lower UTI (191), pyelonephritis (56) and urosepsis (42). In patients admitted to hospital with an ED diagnosis of lower UTI, pyelonephritis or urosepsis, clinical/microbiological evidence of UTI was lacking in 61/103, 33/54 and 31/42 cases respectively. The ED diagnosis was concordant with the main reason for admission in less than 40% of patients with UTI syndromes, and antibiotics were stopped within 72 h in 37/161 patients. CONCLUSIONS: Clinical/microbiological evidence of UTI was lacking in 60-70% of patients, suggesting scope to revise empirical prescribing decisions for UTI syndromes in light of microbial culture and clinical progression.

Survival after cardiac resynchronization therapy: results from 50 084 implantations.

AIMS: Randomized controlled trials have shown that cardiac resynchronization therapy (CRT) prolongs survival in patients with heart failure. No studies have explored survival after CRT in relation to individuals in the general population (relative survival, RS). We sought to determine observed and RS after CRT in a nationwide cohort undergoing CRT. METHODS AND RESULTS: A national administrative database was used to quantify observed mortality for patients undergoing CRT. Relative survival (RS) was quantified using life tables. In 50 084 patients [age 72.1 ± 11.6 years (mean ± standard deviation)] undergoing CRT with (CRT-D) (n = 25 273) or without (CRT-P) defibrillation (n = 24 811) over 8.8 years (median follow-up 2.7 years, interquartile range 1.3-4.8), expected survival decreased with age. Device type, male sex, ischaemic heart disease, diabetes, and chronic kidney disease predicted excess mortality. In multivariate analyses, excess mortality (analogue of RS) was lower after CRT-D than after CRT-P in all patients [adjusted hazard ratio (aHR) 0.80, 95% confidence interval (CI) 0.76-0.84] as well as in subgroups with (aHR 0.79, 95% CI 0.74-0.84) or without (aHR 0.82, 95% CI 0.74-0.91) ischaemic heart disease. A Charlson Comorbidity Index (CCI) ≥3 portended a higher excess mortality (aHR 3.04, 95% CI 2.76-3.34). Relative survival was higher in 2015-2017 than in 2009-2011 (aHR 0.64, 95% CI 0.59-0.69). CONCLUSION: Reference RS data after CRT is presented. Sex, ischaemic heart disease, diabetes, chronic kidney disease, and CCI were major determinants of RS after CRT. CRT-D was associated with a higher RS than CRT-P in patients with or without ischaemic heart disease. Relative survival after CRT improved from 2009 to 2017.

Growing Oxide Nanowires and Nanowire Networks by Solid State Contact Diffusion into Solution-Processed Thin Films.

New techniques to directly grow metal oxide nanowire networks without the need for initial nanoparticle seed deposition or postsynthesis nanowire casting will bridge the gap between bottom-up formation and top-down processing for many electronic, photonic, energy storage, and conversion technologies. Whether etched top-down, or grown from catalyst nanoparticles bottom-up, nanowire growth relies on heterogeneous material seeds. Converting surface oxide films, ubiquitous in the microelectronics industry, to nanowires and nanowire networks by the incorporation of extra species through interdiffusion can provide an alternative deposition method. It is shown that solution-processed thin films of oxides can be converted and recrystallized into nanowires and networks of nanowires by solid-state interdiffusion of ionic species from a mechanically contacted donor substrate. NaVO3 nanowire networks on smooth Si/SiO2 and granular fluorine-doped tin oxide surfaces can be formed by low-temperature annealing of a Na diffusion species-containing donor glass to a solution-processed V2 O5 thin film, where recrystallization drives nanowire growth according to the crystal habit of the new oxide phase. This technique illustrates a new method for the direct formation of complex metal oxide nanowires on technologically relevant substrates, from smooth semiconductors, to transparent conducting materials and interdigitated device structures.

2D and 3D photonic crystal materials for photocatalysis and electrochemical energy storage and conversion.

This perspective reviews recent advances in inverse opal structures, how they have been developed, studied and applied as catalysts, catalyst support materials, as electrode materials for batteries, water splitting applications, solar-to-fuel conversion and electrochromics, and finally as photonic photocatalysts and photoelectrocatalysts. Throughout, we detail some of the salient optical characteristics that underpin recent results and form the basis for light-matter interactions that span electrochemical energy conversion systems as well as photocatalytic systems. Strategies for using 2D as well as 3D structures, ordered macroporous materials such as inverse opals are summarized and recent work on plasmonic-photonic coupling in metal nanoparticle-infiltrated wide band gap inverse opals for enhanced photoelectrochemistry are provided.

Marine waste derived carbon materials for use as sulfur hosts for Lithium-Sulfur batteries.

Lithium-sulfur batteries are a promising alternative to lithium-ion batteries as they can potentially offer significantly increased capacities and energy densities. The ever-increasing global battery market demonstrates that there will be an ongoing demand for cost effective battery electrode materials. Materials derived from waste products can simultaneously address two of the greatest challenges of today, i.e., waste management and the requirement to develop sustainable materials. In this study, we detail the carbonisation of gelatin from blue shark and chitin from prawns, both of which are currently considered as waste biproducts of the seafood industry. The chemical and physical properties of the resulting carbons are compared through a correlation of results from structural characterisation techniques, including electron imaging, X-ray diffraction, Raman spectroscopy and nitrogen gas adsorption. We investigated the application of the resulting carbons as sulfur-hosting electrode materials for use in lithium-sulfur batteries. Through comprehensive electrochemical characterisation, we demonstrate that value added porous carbons, derived from marine waste are promising electrode materials for lithium-sulfur batteries. Both samples demonstrated impressive capacity retention when galvanostatically cycled at a rate of C/5 for 500 cycles. This study highlights the importance of looking towards waste products as sustainable feeds for battery material production.

Variability and performance of NHS England's 'reason to reside' criteria in predicting hospital discharge in acute hospitals in England: a retrospective, observational cohort study.

OBJECTIVES: NHS England (NHSE) advocates 'reason to reside' (R2R) criteria to support discharge planning. The proportion of patients without R2R and their rate of discharge are reported daily by acute hospitals in England. R2R has no interoperable standardised data model (SDM), and its performance has not been validated. We aimed to understand the degree of intercentre and intracentre variation in R2R-related metrics reported to NHSE, define an SDM implemented within a single centre Electronic Health Record to generate an electronic R2R (eR2R) and evaluate its performance in predicting subsequent discharge. DESIGN: Retrospective observational cohort study using routinely collected health data. SETTING: 122 NHS Trusts in England for national reporting and an acute hospital in England for local reporting. PARTICIPANTS: 6 602 706 patient-days were analysed using 3-month national data and 1 039 592 patient-days, using 3-year single centre data. MAIN OUTCOME MEASURES: Variability in R2R-related metrics reported to NHSE. Performance of eR2R in predicting discharge within 24 hours. RESULTS: There were high levels of intracentre and intercentre variability in R2R-related metrics (p<0.0001) but not in eR2R. Informedness of eR2R for discharge within 24 hours was low (J-statistic 0.09-0.12 across three consecutive years). In those remaining in hospital without eR2R, 61.2% met eR2R criteria on subsequent days (76% within 24 hours), most commonly due to increased NEWS2 (21.9%) or intravenous therapy administration (32.8%). CONCLUSIONS: Reported R2R metrics are highly variable between and within acute Trusts in England. Although case-mix or community care provision may account for some variability, the absence of a SDM prevents standardised reporting. Following the development of a SDM in one acute Trust, the variability reduced. However, the performance of eR2R was poor, prone to change even when negative and unable to meaningfully contribute to discharge planning.

One-Step Grown Carbonaceous Germanium Nanowires and Their Application as Highly Efficient Lithium-Ion Battery Anodes.

Developing a simple, cheap, and scalable synthetic method for the fabrication of functional nanomaterials is crucial. Carbon-based nanowire nanocomposites could play a key role in integrating group IV semiconducting nanomaterials as anodes into Li-ion batteries. Here, we report a very simple, one-pot solvothermal-like growth of carbonaceous germanium (C-Ge) nanowires in a supercritical solvent. C-Ge nanowires are grown just by heating (380-490 °C) a commercially sourced Ge precursor, diphenylgermane (DPG), in supercritical toluene, without any external catalysts or surfactants. The self-seeded nanowires are highly crystalline and very thin, with an average diameter between 11 and 19 nm. The amorphous carbonaceous layer coating on Ge nanowires is formed from the polymerization and condensation of light carbon compounds generated from the decomposition of DPG during the growth process. These carbonaceous Ge nanowires demonstrate impressive electrochemical performance as an anode material for Li-ion batteries with high specific charge values (>1200 mAh g-1 after 500 cycles), greater than most of the previously reported for other "binder-free" Ge nanowire anode materials, and exceptionally stable capacity retention. The high specific charge values and impressively stable capacity are due to the unique morphology and composition of the nanowires.

Simplifying the synthesis of carbon inverse opals.

Carbon inverse opals (IOs) were prepared via a facile synthesis approach using a sucrose-based precursor and polystyrene (PS) spheres as a sacrificial template. During IO preparation, polymer spheres are typically removed by dispersion in organic solvents, such as toluene or tetrahydrofuran. In this study, carbon IOs are prepared with and without removal of PS spheres by toluene to determine the influence of template removal prior to high-temperature treatment on the morphology and chemistry of the resulting carbons. Properties of samples are compared through a systematic investigation by electron microscopy, Fourier-transform infrared spectroscopy and Raman spectroscopy. We demonstrate that a commonly used processing step-polymer sphere template chemical removal-does not make any significant difference to the IO morphology. A correlation of Raman spectroscopy with SEM imaging and TGA analysis indicates that carbon IOs prepared without the solvent-treatment step are more ordered than samples prepared with this processing step. The key finding of this report is the simplified IO synthesis procedure, which can be adapted to the preparation of IOs of other materials besides carbon.

Development of risk prediction models to predict urine culture growth for adults with suspected urinary tract infection in the emergency department: protocol for an electronic health record study from a single UK university hospital.

BACKGROUND: Urinary tract infection (UTI) is a leading cause of hospital admissions and is diagnosed based on urinary symptoms and microbiological cultures. Due to lags in the availability of culture results of up to 72 h, and the limitations of routine diagnostics, many patients with suspected UTI are started on antibiotic treatment unnecessarily. Predictive models based on routinely collected clinical information may help clinicians to rule out a diagnosis of bacterial UTI in low-risk patients shortly after hospital admission, providing additional evidence to guide antibiotic treatment decisions. METHODS: Using electronic hospital records from Queen Elizabeth Hospital Birmingham (QEHB) collected between 2011 and 2017, we aim to develop a series of models that estimate the probability of bacterial UTI at presentation in the emergency department (ED) among individuals with suspected UTI syndromes. Predictions will be made during ED attendance and at different time points after hospital admission to assess whether predictive performance may be improved over time as more information becomes available about patient status. All models will be externally validated for expected future performance using QEHB data from 2018/2019. DISCUSSION: Risk prediction models using electronic health records offer a new approach to improve antibiotic prescribing decisions, integrating clinical and demographic data with test results to stratify patients according to their probability of bacterial infection. Used in conjunction with expert opinion, they may help clinicians to identify patients that benefit the most from early antibiotic cessation.

Comparing nanoparticles for drug delivery: The effect of physiological dispersion media on nanoparticle properties.

Delivering therapeutics to disease sites is a challenge facing modern medicine. Nanoparticle delivery systems are of considerable interest to overcome this challenge, but these systems suffer from poor clinical translation. It is believed this is, in part, due to incomplete understanding of nanoparticle physico-chemical properties in vivo. To understand how nanoparticle properties could change following intravenous delivery, Au, Ag, Fe2O3, TiO2, and ZnO nanoparticles of 5, 20, and 50 nm were characterised in water and physiological fluids. The effects of the dispersion medium, concentration, and incubation time on size, dispersion, and zeta potential were measured. Properties varied significantly depending on material type, size, and concentration over 24 h. Gold and silver nanoparticles were generally the most stable. Meanwhile, 20 nm nanoparticles appeared to be the least stable size, across materials. These results could have important implications for selecting nanoparticles for drug delivery that will elicit the desired physiological response.

Ethnicity and risk of death in patients hospitalised for COVID-19 infection in the UK: an observational cohort study in an urban catchment area.

BACKGROUND: Studies suggest that certain black and Asian minority ethnic groups experience poorer outcomes from COVID-19, but these studies have not provided insight into potential reasons for this. We hypothesised that outcomes would be poorer for those of South Asian ethnicity hospitalised from a confirmed SARS-CoV-2 infection, once confounding factors, health-seeking behaviours and community demographics were considered, and that this might reflect a more aggressive disease course in these patients. METHODS: Patients with confirmed SARS-CoV-2 infection requiring admission to University Hospitals Birmingham NHS Foundation Trust (UHB) in Birmingham, UK between 10 March 2020 and 17 April 2020 were included. Standardised admission ratio (SAR) and standardised mortality ratio (SMR) were calculated using observed COVID-19 admissions/deaths and 2011 census data. Adjusted HR for mortality was estimated using Cox proportional hazard model adjusting and propensity score matching. RESULTS: All patients admitted to UHB with COVID-19 during the study period were included (2217 in total). 58% were male, 69.5% were white and the majority (80.2%) had comorbidities. 18.5% were of South Asian ethnicity, and these patients were more likely to be younger and have no comorbidities, but twice the prevalence of diabetes than white patients. SAR and SMR suggested more admissions and deaths in South Asian patients than would be predicted and they were more likely to present with severe disease despite no delay in presentation since symptom onset. South Asian ethnicity was associated with an increased risk of death, both by Cox regression (HR 1.4, 95% CI 1.2 to 1.8), after adjusting for age, sex, deprivation and comorbidities, and by propensity score matching, matching for the same factors but categorising ethnicity into South Asian or not (HR 1.3, 95% CI 1.0 to 1.6). CONCLUSIONS: Those of South Asian ethnicity appear at risk of worse COVID-19 outcomes. Further studies need to establish the underlying mechanistic pathways.

Sex-Specific Differences in Survival and Heart Failure Hospitalization After Cardiac Resynchronization Therapy With or Without Defibrillation.

Background Women are underrepresented in cardiac resynchronization therapy (CRT) trials. Some studies suggest that women fare better than men after CRT. We sought to explore clinical outcomes in women and men undergoing CRT-defibrillation or CRT-pacing in real-world clinical practice. Methods and Results A national database (Hospital Episode Statistics for England) was used to quantify clinical outcomes in 43 730 patients (women: 10 890 [24.9%]; men: 32 840 [75.1%]) undergoing CRT over 7.6 years, (median follow-up 2.2 years, interquartile range, 1-4 years). In analysis of the total population, the primary end point of total mortality (adjusted hazard ratio [aHR], 0.73; 95% CI, 0.69-0.76) and the secondary end point of total mortality or heart failure hospitalization (aHR, 0.79, 95% CI 0.75-0.82) were lower in women, independent of known confounders. Total mortality (aHR, 0.73; 95% CI, 0.70-0.76) and total mortality or heart failure hospitalization (aHR, 0.79; 95% CI, 0.75-0.82) were lower for CRT-defibrillation than for CRT-pacing. In analyses of patients with (aHR, 0.89; 95% CI, 0.80-0.98) or without (aHR, 0.70; 95% CI, 0.66-0.73) a myocardial infarction, women had a lower total mortality. In sex-specific analyses, total mortality was lower after CRT-defibrillation in women (aHR, 0.83; P=0.013) and men (aHR, 0.69; P<0.001). Conclusions Compared with men, women lived longer and were less likely to be hospitalized for heart failure after CRT. In both sexes, CRT-defibrillation was superior to CRT-pacing with respect to survival and heart failure hospitalization. The longest survival after CRT was observed in women without a history of myocardial infarction.

Identifying cardiac surgery operations in hospital episode statistics administrative database, with an OPCS-based classification of procedures, validated against clinical data.

OBJECTIVES: Administrative databases with dedicated coding systems in healthcare systems where providers are funded based on services recorded have been shown to be useful for clinical research, although their reliability is still questioned. We devised a custom classification of procedures and algorithms based on OPCS, enabling us to identify open heart surgeries from the English administrative database, Hospital Episode Statistics, with the objective of comparing the incidence of cardiac procedures in administrative and clinical databases. DESIGN: A comparative study of the incidence of cardiac procedures in administrative and clinical databases. SETTING: Data from all National Health Service Trusts in England, performing cardiac surgery. PARTICIPANTS: Patients classified as having cardiac surgery across England between 2004 and 2015, using a combination of procedure codes, age >18 and consultant specialty, where the classification was validated against internal and external benchmarks. RESULTS: We identified a total of 296 426 cardiac surgery procedures, of which majority of the procedures were coronary artery bypass grafting (CABG), aortic valve replacement (AVR), mitral repair and aortic surgery. The matching at local level was 100% for CABG and transplant, >90% for aortic valve and major aortic procedures and >80% for mitral. At national level, results were similar for CABG (IQR 98.6%-104%), AVR (IQR 105%-118%) and mitral valve replacement (IQR 86.2%-111%). CONCLUSIONS: We set up a process which can identify cardiac surgeries in England from administrative data. This will lead to the development of a risk model to predict early and late postoperative mortality, useful for risk stratification, risk prediction, benchmarking and real-time monitoring. Once appropriately adjusted, the system can be applied to other specialties, proving especially useful in those areas where clinical databases are not fully established.

Polysulfide Binding to Several Nanoscale Magnéli Phases Synthesized in Carbon for Long-Life Lithium-Sulfur Battery Cathodes.

In Li-S batteries, it is important to ensure efficient reversible conversion of sulfur to lithium polysulfide (LiPS). Shuttling effects caused by LiPS dissolution can lead to reduced performance and cycle life. Although carbon materials rely on physical trapping of polysulfides, polar oxide surfaces can chemically bind LiPS to improve the stability of sulfur cathodes. We show a simple synthetic method that allows high sulfur loading into mesoporous carbon preloaded with spatially localized nanoparticles of several Magnéli-phase titanium oxide (Tin O2n-1 ). This material simultaneously suppresses polysulfide shuttling phenomena by chemically binding Li polysulfides onto several Magnéli-phase surfaces in a single cathode and ensures physical confinement of sulfur and LiPS. The synergy between chemical immobilization of significant quantities of LiPS at the surface of several Tin O2n-1 phases and physical entrapment results in coulombically efficient high-rate cathodes with long cycle life and high capacity. These cathodes function efficiently at low electrolyte-to-sulfur ratios to provide high gravimetric and volumetric capacities in comparison with their highly porous carbon counterparts. Assembled coin cells have an initial discharge capacity of 1100 mAh g-1 at 0.1C and maintain a reversible capacity of 520 mAh g-1 at 0.2C for more than 500 cycles. Even at 1C, the cell loses only 0.06 % per cycle for 1000 cycles with a coulombic efficiency close to 99 %.

Clinical outcomes and costs of cardiac revascularisation in England and New York state.

Objectives: Healthcare expenditure per-capita in the USA is higher than in England. We hypothesised that clinical outcomes after cardiac revascularisation are better in the USA. We compared costs and outcomes of patients undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in England and New York State (NYS). Methods: Costs and total mortality were assessed using the Hospital Episode Statistics for England and the Statewide Planning and Research Cooperative System for NYS. Outcomes after a first CABG or PCI were assessed in patients undergoing a first CABG (n=142 969) or PCI (n=431 416). Results: After CABG, crude total mortality in England was 0.72% lower at 30 days and 3.68% lower at 1 year (both P<0.001). After PCI, crude total mortality was 0.35% lower at 30 days and 3.55% lower at 1 year (both P<0.001). No differences emerged in total mortality at 30 days after either CABG (England: HR 1.02,95% CI 0.94 to 1.10) or PCI (HR 1.04, 95% CI 0.99 to 1.09) after covariate adjustment. At 1 year, adjusted total mortality was lower in England after both CABG (HR 0.74, 95% CI 0.71 to 0.78) and PCI (HR 0.66, 95% CI 0.65 to 0.68). After adjustment for cost-to-charge ratios and purchasing power parities, costs in NYS amounted to uplifts of 3.8-fold for CABG and 3.6-fold for PCI. Conclusions: Total mortality after CABG and PCI was similar at 30 days and lower in England at 1 year. Costs were approximately fourfold higher in NYS.

Carbon-Coated Honeycomb Ni-Mn-Co-O Inverse Opal: A High Capacity Ternary Transition Metal Oxide Anode for Li-ion Batteries.

We present the formation of a carbon-coated honeycomb ternary Ni-Mn-Co-O inverse opal as a conversion mode anode material for Li-ion battery applications. In order to obtain high capacity via conversion mode reactions, a single phase crystalline honeycombed IO structure of Ni-Mn-Co-O material was first formed. This Ni-Mn-Co-O IO converts via reversible redox reactions and Li2O formation to a 3D structured matrix assembly of nanoparticles of three (MnO, CoO and NiO) oxides, that facilitates efficient reactions with Li. A carbon coating maintains the structure without clogging the open-worked IO pore morphology for electrolyte penetration and mass transport of products during cycling. The highly porous IO was compared in a Li-ion half-cell to nanoparticles of the same material and showed significant improvement in specific capacity and capacity retention. Further optimization of the system was investigated by incorporating a vinylene carbonate additive into the electrolyte solution which boosted performance, offering promising high-rate performance and good capacity retention over extended cycling. The analysis confirms the possibility of creating a ternary transition metal oxide material with binder free accessible open-worked structure to allow three conversion mode oxides to efficiently cycle as an anode material for Li-ion battery applications.