An Analysis of Healthcare Usage & Place of Death in England for All Adults Who Died in 2021/22.

OBJECTIVE: We wanted to examine the healthcare use and non-elective activity in the UK population of expected deaths over an 1-year period to highlight and examine the reasons for variation. We did this to identify areas to focus interventions or resources on to reduce unnecessary emergency care use at the end of life. METHODS AND ANALYSIS: We assembled a data set of approximately 400 000 adults who died in England in the financial year 2021/22 (April 2021-March 2022). Any adults classified as a 'sudden death' were excluded. We used available data to ensure outcome measures were relevant used expert consensus to agree what to examine. We recorded place of death and examined urgent care in terms of admissions in the last year and 90 days of life. We also used recorded hospital care days as elective and non-elective usage. RESULTS: There were over 400 000 decedents included in our regression models. Close to half died in hospital (44%). Three-quarters (77%) had at least one day of unplanned hospital care in the 90 days before they died, and half (56%) had at least one day of planned hospital care. CONCLUSION: Reliance on urgent care for those approaching end-of-life may indicate poor care planning and integration of services. A relatively modest increase in the amount of community care a person receives at end-of-life can substantially reduce the likelihood of dying in hospital. Those with a cancer cause of death are far less likely to die in hospital.

Correcting for Antibody Waning in Cumulative Incidence Estimation from Sequential Serosurveys.

Serosurveys are a widely used tool to estimate the cumulative incidence, i.e. the fraction of a population that have been infected by a given pathogen. These surveys rely on serological assays that measure the level of pathogen-specific antibodies. Because antibody levels are waning, the fraction of previously infected individuals that have sero-reverted increases with time past infection. To avoid underestimating the true cumulative incidence, it is therefore essential to correct for waning antibody levels. We present an empirically-supported approach for sero-reversion correction in cumulative incidence estimation when sequential serosurveys are conducted in the context of a newly emerging infectious disease. The correction is based on the observed dynamics of antibody titers in sero-positive cases and validated using several in silico test scenarios. Furthermore, through this approach we revise a previous cumulative incidence estimate, which relies on the assumption of an exponentially-declining probability of sero-reversion over time, of SARS-CoV-2 of 76% in Manaus, Brazil, by October 2020 to 47.6% (43.5% - 53.5%). This estimate has implications e.g. for the proximity to herd immunity in Manaus in late 2020.

Test-trace-isolate-quarantine (TTIQ) intervention strategies after symptomatic COVID-19 case identification.

The test-trace-isolate-quarantine (TTIQ) strategy, where confirmed-positive pathogen carriers are isolated from the community and their recent close contacts are identified and pre-emptively quarantined, is used to break chains of transmission during a disease outbreak. The protocol is frequently followed after an individual presents with disease symptoms, at which point they will be tested for the pathogen. This TTIQ strategy, along with hygiene and social distancing measures, make up the non-pharmaceutical interventions that are utilised to suppress the ongoing COVID-19 pandemic. Here we develop a tractable mathematical model of disease transmission and the TTIQ intervention to quantify how the probability of detecting and isolating a case following symptom onset, the fraction of contacts that are identified and quarantined, and the delays inherent to these processes impact epidemic growth. In the model, the timing of disease transmission and symptom onset, as well as the frequency of asymptomatic cases, is based on empirical distributions of SARS-CoV-2 infection dynamics, while the isolation of confirmed cases and quarantine of their contacts is implemented by truncating their respective infectious periods. We find that a successful TTIQ strategy requires intensive testing: the majority of transmission is prevented by isolating symptomatic individuals and doing so in a short amount of time. Despite the lesser impact, additional contact tracing and quarantine increases the parameter space in which an epidemic is controllable and is necessary to control epidemics with a high reproductive number. TTIQ could remain an important intervention for the foreseeable future of the COVID-19 pandemic due to slow vaccine rollout and highly-transmissible variants with the potential for vaccine escape. Our results can be used to assess how TTIQ can be improved and optimised, and the methodology represents an improvement over previous quantification methods that is applicable to future epidemic scenarios.

Constrained optimization of divisional load in hierarchically organized tissues during homeostasis.

It has been hypothesized that the structure of tissues and the hierarchy of differentiation from stem cell to terminally differentiated cell play a significant role in reducing the incidence of cancer in that tissue. One specific mechanism by which this risk can be reduced is by minimizing the number of divisions-and hence the mutational risk-that cells accumulate as they divide to maintain tissue homeostasis. Here, we investigate a mathematical model of cell division in a hierarchical tissue, calculating and minimizing the divisional load while constraining parameters such that homeostasis is maintained. We show that the minimal divisional load is achieved by binary division trees with progenitor cells incapable of self-renewal. Contrary to the protection hypothesis, we find that an increased stem cell turnover can lead to lower divisional load. Furthermore, we find that the optimal tissue structure depends on the time horizon of the duration of homeostasis, with faster stem cell division favoured in short-lived organisms and more progenitor compartments favoured in longer-lived organisms.

Relationship Between Distinct Physical Capacities in Young Welsh Rugby Players.

ABSTRACT: Loturco, I, Ashcroft, P, Evans, N, Tombs, C, Pereira, LA, and Jeffreys, I. Relationship between distinct physical capacities in young Welsh rugby players. J Strength Cond Res 36(2): 441-447, 2022-We examined the correlations between aerobic fitness (assessed by the 30-15 intermittent fitness test [IFT]), maximum isometric strength, vertical jump, and speed performance of 37 under-16 (U16) Welsh regional rugby players. The physical assessments used in this research are part of a regional development program under the auspices of the players' development pathway created by the Welsh Rugby Union. The tests were performed in the following order: vertical jumps, isometric midthigh pull, 40-m sprint velocity, and 30-15 IFT. A Pearson's product moment correlation coefficient was used to estimate the magnitude of the relationships between the different physical variables. Overall, we found significant associations between jump height, sprint velocity, maximum isometric strength, and 30-15 IFT performance (r ranging from 0.44 to 0.70). Moreover, strong positive interrelationships were observed between strength, speed, and jump qualities (r ranging from 0.51 to 0.80). Although these findings remain to be established in prospective studies, it seems that U16 athletes are capable of simultaneously improving their aerobic fitness and neuromuscular performance. This can be confirmed by the close correlations between the 30-15 IFT and every neuromechanical parameter reported here. Therefore, practitioners are recommended to use multifaceted training schemes with their young rugby players, including different components of endurance, speed, strength, and power training.

Myeloproliferative Neoplasms: The Long Wait for JAK2-Mutant Clone Expansion.

Myeloproliferative neoplasms (MPNs) are hematological malignancies caused by somatic mutations originating from a single hematopoietic stem cell (HSC). In this issue of Cell Stem Cell,Van Egeren et al. (2021) used whole-genome sequencing of hematopoietic colonies to reconstruct the clonal history and time of acquisition of the disease-initiating gene mutation.

Quantifying the impact of quarantine duration on COVID-19 transmission.

The large number of individuals placed into quarantine because of possible severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) exposure has high societal and economic costs. There is ongoing debate about the appropriate duration of quarantine, particularly since the fraction of individuals who eventually test positive is perceived as being low. We use empirically determined distributions of incubation period, infectivity, and generation time to quantify how the duration of quarantine affects onward transmission from traced contacts of confirmed SARS-CoV-2 cases and from returning travellers. We also consider the roles of testing followed by release if negative (test-and-release), reinforced hygiene, adherence, and symptoms in calculating quarantine efficacy. We show that there are quarantine strategies based on a test-and-release protocol that, from an epidemiological viewpoint, perform almost as well as a 10-day quarantine, but with fewer person-days spent in quarantine. The findings apply to both travellers and contacts, but the specifics depend on the context.

The COVID-19 pandemic has led many countries to impose quarantines, ensuring that people who may have been exposed to the SARS-CoV-2 virus or who return from abroad are isolated for a specific period to prevent the spread of the disease. These measures have crippled travel, taken a large economic toll, and affected the wellbeing of those needing to self-isolate. However, there is no consensus on how long COVID-19 quarantines should be. Reducing the duration of quarantines could significantly decrease the costs of COVID-19 to the overall economy and to individuals, so Ashcroft et al. decided to examine how shorter isolation periods and test-and-release schemes affected transmission. Existing data on how SARS-CoV-2 behaves in a population were used to generate a model that would predict how changing quarantine length impacts transmission for both travellers and people who may have been exposed to the virus. The analysis predicted that shortening quarantines from ten to seven days would result in almost no increased risk of transmission, if paired with PCR testing on day five of isolation (with people testing positive being confined for longer). The quarantine could be cut further to six days if rapid antigen tests were used. Ashcroft et al.'s findings suggest that it may be possible to shorten COVID-19 quarantines if good testing approaches are implemented, leading to better economic, social and individual outcomes.

On the relationship between serial interval, infectiousness profile and generation time.

The timing of transmission plays a key role in the dynamics and controllability of an epidemic. However, observing generation times-the time interval between the infection of an infector and an infectee in a transmission pair-requires data on infection times, which are generally unknown. The timing of symptom onset is more easily observed; generation times are therefore often estimated based on serial intervals-the time interval between symptom onset of an infector and an infectee. This estimation follows one of two approaches: (i) approximating the generation time distribution by the serial interval distribution or (ii) deriving the generation time distribution from the serial interval and incubation period-the time interval between infection and symptom onset in a single individual-distributions. These two approaches make different-and not always explicitly stated-assumptions about the relationship between infectiousness and symptoms, resulting in different generation time distributions with the same mean but unequal variances. Here, we clarify the assumptions that each approach makes and show that neither set of assumptions is plausible for most pathogens. However, the variances of the generation time distribution derived under each assumption can reasonably be considered as upper (approximation with serial interval) and lower (derivation from serial interval) bounds. Thus, we suggest a pragmatic solution is to use both approaches and treat these as edge cases in downstream analysis. We discuss the impact of the variance of the generation time distribution on the controllability of an epidemic through strategies based on contact tracing, and we show that underestimating this variance is likely to overestimate controllability.

Stochastic Gene Expression Influences the Selection of Antibiotic Resistance Mutations.

Bacteria can resist antibiotics by expressing enzymes that remove or deactivate drug molecules. Here, we study the effects of gene expression stochasticity on efflux and enzymatic resistance. We construct an agent-based model that stochastically simulates multiple biochemical processes in the cell and we observe the growth and survival dynamics of the cell population. Resistance-enhancing mutations are introduced by varying parameters that control the enzyme expression or efficacy. We find that stochastic gene expression can cause complex dynamics in terms of survival and extinction for these mutants. Regulatory mutations, which augment the frequency and duration of resistance gene transcription, can provide limited resistance by increasing mean expression. Structural mutations, which modify the enzyme or efflux efficacy, provide most resistance by improving the binding affinity of the resistance protein to the antibiotic; increasing the enzyme's catalytic rate alone may contribute to resistance if drug binding is not rate limiting. Overall, we identify conditions where regulatory mutations are selected over structural mutations, and vice versa. Our findings show that stochastic gene expression is a key factor underlying efflux and enzymatic resistances and should be taken into consideration in future antibiotic research.

Clonal dominance and transplantation dynamics in hematopoietic stem cell compartments.

Hematopoietic stem cells in mammals are known to reside mostly in the bone marrow, but also transitively passage in small numbers in the blood. Experimental findings have suggested that they exist in a dynamic equilibrium, continuously migrating between these two compartments. Here we construct an individual-based mathematical model of this process, which is parametrised using existing empirical findings from mice. This approach allows us to quantify the amount of migration between the bone marrow niches and the peripheral blood. We use this model to investigate clonal hematopoiesis, which is a significant risk factor for hematologic cancers. We also analyse the engraftment of donor stem cells into non-conditioned and conditioned hosts, quantifying the impact of different treatment scenarios. The simplicity of the model permits a thorough mathematical analysis, providing deeper insights into the dynamics of both the model and of the real-world system. We predict the time taken for mutant clones to expand within a host, as well as chimerism levels that can be expected following transplantation therapy, and the probability that a preconditioned host is reconstituted by donor cells.

Effects of population growth on the success of invading mutants.

Understanding if and how mutants reach fixation in populations is an important question in evolutionary biology. We study the impact of population growth has on the success of mutants. To systematically understand the effects of growth we decouple competition from reproduction; competition follows a birth-death process and is governed by an evolutionary game, while growth is determined by an externally controlled branching rate. In stochastic simulations we find non-monotonic behaviour of the fixation probability of mutants as the speed of growth is varied; the right amount of growth can lead to a higher success rate. These results are observed in both coordination and coexistence game scenarios, and we find that the 'one-third law' for coordination games can break down in the presence of growth. We also propose a simplified description in terms of stochastic differential equations to approximate the individual-based model.

When the mean is not enough: Calculating fixation time distributions in birth-death processes.

Studies of fixation dynamics in Markov processes predominantly focus on the mean time to absorption. This may be inadequate if the distribution is broad and skewed. We compute the distribution of fixation times in one-step birth-death processes with two absorbing states. These are expressed in terms of the spectrum of the process, and we provide different representations as forward-only processes in eigenspace. These allow efficient sampling of fixation time distributions. As an application we study evolutionary game dynamics, where invading mutants can reach fixation or go extinct. We also highlight the median fixation time as a possible analog of mixing times in systems with small mutation rates and no absorbing states, whereas the mean fixation time has no such interpretation.

Stochastic tunneling and metastable states during the somatic evolution of cancer.

Tumors initiate when a population of proliferating cells accumulates a certain number and type of genetic and/or epigenetic alterations. The population dynamics of such sequential acquisition of (epi)genetic alterations has been the topic of much investigation. The phenomenon of stochastic tunneling, where an intermediate mutant in a sequence does not reach fixation in a population before generating a double mutant, has been studied using a variety of computational and mathematical methods. However, the field still lacks a comprehensive analytical description since theoretical predictions of fixation times are available only for cases in which the second mutant is advantageous. Here, we study stochastic tunneling in a Moran model. Analyzing the deterministic dynamics of large populations we systematically identify the parameter regimes captured by existing approaches. Our analysis also reveals fitness landscapes and mutation rates for which finite populations are found in long-lived metastable states. These are landscapes in which the final mutant is not the most advantageous in the sequence, and resulting metastable states are a consequence of a mutation-selection balance. The escape from these states is driven by intrinsic noise, and their location affects the probability of tunneling. Existing methods no longer apply. In these regimes it is the escape from the metastable states that is the key bottleneck; fixation is no longer limited by the emergence of a successful mutant lineage. We used the so-called Wentzel-Kramers-Brillouin method to compute fixation times in these parameter regimes, successfully validated by stochastic simulations. Our work fills a gap left by previous approaches and provides a more comprehensive description of the acquisition of multiple mutations in populations of somatic cells.

Fixation in finite populations evolving in fluctuating environments.

The environment in which a population evolves can have a crucial impact on selection. We study evolutionary dynamics in finite populations of fixed size in a changing environment. The population dynamics are driven by birth and death events. The rates of these events may vary in time depending on the state of the environment, which follows an independent Markov process. We develop a general theory for the fixation probability of a mutant in a population of wild-types, and for mean unconditional and conditional fixation times. We apply our theory to evolutionary games for which the payoff structure varies in time. The mutant can exploit the environmental noise; a dynamic environment that switches between two states can lead to a probability of fixation that is higher than in any of the individual environmental states. We provide an intuitive interpretation of this surprising effect. We also investigate stationary distributions when mutations are present in the dynamics. In this regime, we find two approximations of the stationary measure. One works well for rapid switching, the other for slowly fluctuating environments.

Pattern formation in individual-based systems with time-varying parameters.

We study the patterns generated in finite-time sweeps across symmetry-breaking bifurcations in individual-based models. Similar to the well-known Kibble-Zurek scenario of defect formation, large-scale patterns are generated when model parameters are varied slowly, whereas fast sweeps produce a large number of small domains. The symmetry breaking is triggered by intrinsic noise, originating from the discrete dynamics at the microlevel. Based on a linear-noise approximation, we calculate the characteristic length scale of these patterns. We demonstrate the applicability of this approach in a simple model of opinion dynamics, a model in evolutionary game theory with a time-dependent fitness structure, and a model of cell differentiation. Our theoretical estimates are confirmed in simulations. In further numerical work, we observe a similar phenomenon when the symmetry-breaking bifurcation is triggered by population growth.

Adapting patient education for potential liver transplant recipients in a climate of chronic donor organ shortfall.

Liver transplantation is the established treatment for selected patients with acute liver failure or decompensated chronic liver disease. The procedure is not without its risks, however, and not every patient will survive. Although seldom recognized in the literature, education of patients is vital to the safety and success of transplantation. Before patients are accepted onto the transplant waiting list, both the patients and their families/caregivers must gain a complete understanding of the transplant process. In Birmingham, patients are not accepted onto the waiting list until a support package is agreed upon and in place. Patients and their partners/caregivers are required to attend a group teaching session presented by the transplant coordinators. This form of group teaching was introduced in response to the ever-increasing workload of the team due to an increase in the number of patients on the waiting list brought about by the chronic shortage of donor organs. An audit of this method of teaching was undertaken, and its effects on patients, their caregivers, and the coordinator team are described.