Association between emergency department attendances, sociodemographic factors and long-term health conditions in the population of Norfolk and Waveney, England: Cross sectional study.

INTRODUCTION: Demand for urgent and emergency health care in England has grown over the last decade, for reasons that are not clear. Changes in population demographics may be a cause. This study investigated associations between individuals' characteristics (including socioeconomic deprivation and long term health conditions (LTC)) and the frequency of emergency department (ED) attendances, in the Norfolk and Waveney subregion of the East of England. METHODS: The study population was people who were registered with 91 of 106 Norfolk and Waveney general practices during one year from 1 April 2022 to 31 March 2023. Linked primary and secondary care and geographical data included each individual's sociodemographic characteristics, and number of ED attendances during the same year and, for some individuals, LTCs and number of general practice (GP) appointments. Associations between these factors and ED attendances were estimated using Poisson regression models. RESULTS: 1,027,422 individuals were included of whom 57.4% had GP data on the presence or absence of LTC, and 43.1% had both LTC and general practitioner appointment data. In the total population ED attendances were more frequent in individuals aged under five years, (adjusted Incidence Rate Ratio (IRR) 1.25, 95% confidence interval 1.23 to 1.28) compared to 15-35 years); living in more socioeconomically deprived areas (IRR 0.61 (0.60 to 0.63)) for least deprived compared to most deprived,and living closer to the nearest ED. Among individuals with LTC data, each additional LTC was also associated with increased ED attendances (IRR 1.16 (1.15 to 1.16)). Among individuals with LTC and GP appointment data, each additional GP appointment was also associated with increased ED attendances (IRR 1.03 (1.026 to 1.027)). CONCLUSIONS: In the Norfolk and Waveney population, ED attendance rates were higher for young children and individuals living in more deprived areas and closer to EDs. In individuals with LTC and GP appointment data, both factors were also associated with higher ED attendance.

Impact of NICE clinical guidelines for prevention and treatment of neonatal infections on antibiotic use in very preterm infants in England and Wales: an interrupted time series analysis.

OBJECTIVE: To assess the impact of publication of UK National Institute for Health and Care Excellence (NICE) guidelines on the prevention and treatment of early-onset infections (EOIs) in neonates (clinical guideline 149 (CG149), published in 2012, and its 2021 update (NG195) on antibiotic use in very preterm infants. DESIGN: Interrupted time series analysis using data from the National Neonatal Research Database. SETTING: Neonatal units in England and Wales. PARTICIPANTS: Infants born at 22-31 weeks' gestation from 1 January 2010 to 31 December 2022 and survived to discharge. INTERVENTIONS: Publication of CG149 (August 2012) and NG195 (April 2021). MAIN OUTCOME MEASURES: Measures of antibiotic use, aggregated by month of birth: antibiotic use rate (AUR), the proportion of care days in receipt of at least one antibiotic; percentage of infants who received ≥1 day of antibiotics on days 1-3 for EOI and after day 3 for late-onset infection (LOI); percentage who received ≥1 prolonged antibiotic course ≥5 days for EOI and LOI. RESULTS: 96% of infants received an antibiotic during inpatient stay. AUR declined at publication of CG149, without further impact at NG195 publication. There was no impact of CG149 on the underlying trend in infants receiving ≥1 day antibiotics for EOI or LOI, but post-NG195 the monthly trend began to decline for EOI (-0.20%, -0.26 to -0.14) and LOI (-0.23%, -0.33 to -0.12). Use of prolonged antibiotic courses for EOI and LOI declined at publication of CG149 and for LOI this trend accelerated post-NG195. CONCLUSIONS: Publications of NICE guidance were associated with reductions in antibiotic use; however neonatal antibiotic exposure remains extremely high.

Using geospatial mapping to predict and compare gambling harm hotspots in urban, rural and coastal areas of a large county in England.

BACKGROUND: Disordered gambling is a public health problem with interconnections with health and social inequality, and adverse impacts on physical and mental health. Mapping technologies have been used to explore gambling in the UK, though most were based in urban locations. METHODS: We used routine data sources and geospatial mapping software to predict where gambling related harm would be most prevalent within a large English county, host to urban, rural and coastal communities. RESULTS: Licensed gambling premises were most concentrated in areas of deprivation, and in urban and coastal areas. The aggregate prevalence of disordered gambling associated characteristics was also greatest in these areas. CONCLUSIONS: This mapping study links the number of gambling premises, deprivation, and risk factors for disordered gambling, and highlights that coastal areas see particularly high density of gambling premises. Findings can be applied to target resources to where they are most needed.

The indirect effects of COVID-19 upon global childhood pneumonia.

OBJECTIVES: The relative scarcity of paediatric COVID-19 disease infers protection from its direct harms. We aim to highlight the potentially severe indirect effects of COVID-19 upon global childhood pneumonia. STUDY DESIGN: This is a discussion piece written from the authors' perspective. METHODS: We use the social determinants of health to describe the indirect impact of COVID-19 upon global childhood pneumonia. RESULTS: The social determinants of health are a range of social, economic, and environmental factors used to explore and explain global health differences and inequalities. Global childhood pneumonia is a significant public health problem with clear linkage to the social determinants of health. COVID-19 is a significant threat to the health and wellbeing of children around the world through its potentially severe effects on all strata of the social determinants of health. CONCLUSIONS: The COVID-19 pandemic could undermine years of progress in reducing both global childhood pneumonia incidence and mortality, and most significantly affect vulnerable children living in poverty.

The importance of a supportive environment in clinical audit: a pilot study of doctors' engagement with the NHS National PET-CT audit programme.

PURPOSE: The NHS National PET-CT Audit Programme was launched in 2008 as part of a national NHS programme to widen patient access to PET-computed tomography (CT) imaging in England. However, to implement clinical audit effectively, healthcare professionals need to be fully engaged with the process. The purpose of the pilot study was to identify and explore the different factors that influence doctors' engagement with the National NHS PET-CT Audit Programme. METHODS: A single embedded case study was undertaken, which centred on the NHS National PET-CT Audit Programme. Seven theoretical propositions drawn from a review of the literature were tested and their influence evaluated. A purposeful sample of 13 semistructured interviews with consultant doctors was taken from different hospitals over a 6-month period. The data were analysed using directed thematic content analysis, with the themes compared against the study's propositions. RESULTS: Doctors' perspectives of clinical audit changed in response to the way in which the audit was implemented. The main barriers to engagement were the lack of a common vision and poor communication, which contributed to poor interprofessional relationships and a perceived culture of blame. In contrast, factors that facilitated engagement centred on the adoption of a more supportive and collaborative approach, which in turn facilitated higher levels of trust between professionals. The dissemination of performance data was found to be a key influencing factor. CONCLUSION: The study makes use of a unique data set and to the best of our knowledge is one of the first studies to document how the dissemination of doctors' performance data positively influences engagement with clinical audit in England. In addition, the study also shows how, contrary to some studies in the literature, clinical audit can reduce professional anxiety by providing a validation of professional competence. The study supports the premise that clinical audit will be fully embraced by doctors only if they are sufficiently involved in the process so as to be able to redefine and clarify its purpose and meaning. The preliminary findings of this pilot study provide the theoretical underpinning for a national survey into reporter perspectives of the National PET-CT Audit Programme.

Gut microbes contribute to nitrogen provisioning in a wood-feeding cerambycid.

Xylophagous insects often thrive on nutritionally suboptimal diets through symbiotic associations with microbes that supplement their nutritional requirements, particularly nitrogen. The wood-feeding cerambycid Anoplophora glabripennis (Motschulsky) feeds on living, healthy host trees and harbors a diverse gut microbial community. We investigated gut microbial contributions to larval nitrogen requirements through nitrogen fixing and recycling (urea hydrolysis) processes, using a combination of molecular, biochemical, and stable isotope approaches. Genes and transcripts of conserved regions of the urease operon (ureC) and nitrogen fixing (nif) regulon (nifH) were detected in A. glabripennis eggs and larvae from naturally infested logs and from larvae reared on artificial diet. Significant nitrogen fixation and recycling were documented in larvae using (15)N2 gas and (15)N-urea, respectively. Subsequent (15)N-routing of incorporated recycled nitrogen into larval essential and nonessential amino acids was shown for (15)N-urea diet-fed larvae. Results from this study show significant gut microbial contributions to this insect's metabolic nitrogen utilization through nitrogenous waste product recycling and nitrogen fixation.

Does stenting of left-sided colorectal cancer as a "bridge to surgery" adversely affect oncological outcomes? A comparison with non-obstructing elective left-sided colonic resections.

PURPOSE: With a theoretical link between stent insertion and increased risk of tumour seeding, there is concern about long-term survival after the use of self-expanding metallic stents (SEMS) as a "bridge to surgery" in the treatment of left-sided obstructing colorectal cancer. This cohort study aims to determine if preoperative stenting adversely affects long-term survival by comparing a group of patients having preoperative stenting (group A) with a group of patients having elective surgery (group B) in a single centre. METHODS: The study is retrospective. Survival was calculated with Kaplan-Meier analysis and compared using the log-rank test. Other group characteristics were compared with Fisher's exact test. RESULTS: From November 1998 to November 2008, 15 patients had preoperative SEMS and were entered in group A. This represented 11.5 % of a total of 130 patients undergoing SEMS insertion in the same period. Group B included 88 consecutive patients undergoing elective left-sided colonic resection for Dukes' B and C cancer excluding mid and low rectal tumours between January 2003 and December 2007. The 30-day mortality rate for groups A and B was 6.7 % (one patient) and 5.7 % (five patients), respectively. The 5-year survival rate was 60 % and 58 %, respectively, with a p value of 0.96. CONCLUSIONS: In our own practice, patients undergoing SEMS as a "bridge to surgery" have the same long-term survival with those undergoing elective surgery. This finding needs to be confirmed in larger scale studies.

Shortcomings in colonic stenting to palliate large bowel obstruction from extracolonic malignancies.

AIM: The aim of this study is to report our experience gained after attempted colonic stenting for colonic obstruction from extracolonic cancer. METHOD This is a retrospective study of all patients who had attempted colonic stenting for obstructing extracolonic cancer in a district general hospital from November 1998 to November 2008. RESULTS: During the study period, a total of 12 stent procedures were carried out in 11 patients with colonic obstruction from extracolonic cancer and were analysed further. These represented 8.5% of a total of 141 stent procedures performed in 130 patients. Fluoroscopic technique was used alone. The median age was 73 years with a range from 47 to 88 years. The underlying malignancy was ovarian in five, urinary bladder in one, kidney in one, prostatic in one, breast in one, cholangiocarcinoma in one and carcinoid in one. The technical and clinical success rate was 42% and 25%, respectively. The 30-day mortality rate was 36%. Stent-related complications included one perforation. The colostomy formation rate was 45%. Only two patients survived over a month with a stent and without a subsequent colostomy. The median survival time was 2 months. The 3-, 6- and 12-month survival rate was 36%, 18% and 9%, respectively. CONCLUSIONS: Our experience does not support the routine use of colonic stenting for extracolonic cancer obstructing the colon. A more realistic approach is necessary including either the acceptance that the obstruction represents a life-ending event or proceeding immediately to a colostomy. Decisions should be individualised and stenting used after recognising its shortcomings.

Phase II-I-II study of two different doses and schedules of pralatrexate, a high-affinity substrate for the reduced folate carrier, in patients with relapsed or refractory lymphoma reveals marked activity in T-cell malignancies.

PURPOSE: To determine the maximum-tolerated dose (MTD) and efficacy of pralatrexate in patients with lymphoma. PATIENTS AND METHODS: Pralatrexate, initially given at a dose of 135 mg/m(2) on an every-other-week basis, was associated with stomatitis. A redesigned, weekly phase I/II study established an MTD of 30 mg/m(2) weekly for six weeks every 7 weeks. Patients were required to have relapsed/refractory disease, an absolute neutrophil greater than 1,000/microL, and a platelet count greater than 50,000/microL for the first dose of any cycle. RESULTS: The every-other-week, phase II experience was associated with an increased risk of stomatitis and hematologic toxicity. On a weekly schedule, the MTD was 30 mg/m(2) weekly for 6 weeks every 7 weeks. This schedule modification resulted in a 50% reduction in the major hematologic toxicities and abrogation of the grades 3 to 4 stomatitis. Stomatitis was associated with elevated homocysteine and methylmalonic acid, which were reduced by folate and vitamin B12 supplementation. Of 48 assessable patients, the overall response rate was 31% (26% by intention to treat), including 17% who experienced complete remission (CR). When analyzed by lineage, the overall response rates were 10% and 54% in patients with B- and T-cell lymphomas, respectively. All eight patients who experienced CR had T-cell lymphoma, and four of the six patients with a partial remission were positron emission tomography negative. The duration of responses ranged from 3 to 26 months. CONCLUSION: Pralatrexate has significant single-agent activity in patients with relapsed/refractory T-cell lymphoma.

Morning or afternoon emergency list? Effects on service provision and training.

BACKGROUND: In response to the recommendations of the National Confidential Enquiries into Perioperative Deaths many UK hospitals have introduced a half day (morning or afternoon) planned list for emergencies. We have compared two district general hospitals (DGH A and DGH B) within the same Trust with an afternoon and a morning list, respectively, and examine whether there is any effect on the emergency and urgent laparotomy workload. METHODS: We conducted a retrospective comparative audit of emergency and urgent laparotomies performed in a six-month period at the two hospitals. The chi-square test was used for statistical analysis. RESULTS: In DGH A and DGH B, 79 and 73 laparotomies were performed, with 18% and 22% mortality, respectively, (p=0.609). The median age was 74 (18-93) years and 67 (12-92) years and the median postoperative stay was 12 (1-149) days and 14 (4-74) days, respectively. 59 laparotomies were performed during weekdays in DGH A and 51 in DGH B. There was no difference between hospitals in the seniority of the operating surgeon or the level of supervision. DGH A accommodated 24% of its laparotomies on the afternoon emergency list, 39% on elective lists, 29% in the evening, and 8% at night. DGH B accommodated 33% of its laparotomies on the morning emergency list, 8% on elective lists (p=0.001), 51% in the evening (p=0.063), and 8% at night. Overall 63% of laparotomies in DGH A and 41% in DGH B were done during daytime. CONCLUSION: Less than one-third of laparotomies were performed on the emergency list, suggesting underutilisation. The seniority of the surgeon and the level of supervision were similar at both sites. Neither morning nor afternoon proved better in terms of service provision or training opportunities. By accommodating laparotomies onto an elective list DGH A reduced the number of laparotomies performed in the evening.

Patterns of growth compensation in eastern white pine (Pinus strobus L.): the influence of herbivory intensity and competitive environments.

To investigate complex growth compensation patterns, white pine (Pinus strobus L.) seedlings were clipped to simulate different herbivory levels. Seedlings were growing with different understory competition levels (created through monthly weeding vs no brush control) under a range of overstory canopy closures. Compensation patterns varied for the different growth and size measures. After one growing season, seedlings did not fully compensate for lost biomass regardless of the competitive environments of the seedlings. Although relative height growth was stimulated by light intensity clipping (20-40% of last-year shoots removed), relative diameter growth, total biomass, and biomass growth of seedlings declined sharply with increasing clipping intensity. Likewise, all growth parameters declined with increasing interspecific competition. Results showed that seedlings in highly competitive environments showed smaller growth loss due to clipping than those in competition-free environments, presumably because seedlings experiencing high interspecific competition devoted more energy to maintaining apical dominance and a balanced shoot-root ratio. While competition from canopy trees altered compensatory patterns, competition from understory vegetation only altered the magnitude, but not the patterns, of compensatory growth. We suggest that compensatory growth follows a complex pattern that will vary with the parameters measured, competitive conditions, and clipping intensities. Our results support the assertion that overcompensation may be an adaptation to competitive ability, rather than a response to herbivory itself.