Measuring access: how accurate are patient-reported waiting times?

Introduction: A national audit of waiting times in England’s genitourinary medicine clinics measures patient access. Data are collected by patient questionnaires, which rely upon patients’ recollection of first contact with health services, often several days previously. The aim of this study was to assess the accuracy of patient-reported waiting times. Methods: Data on true waiting times were collected at the time of patient booking over a three-week period and compared with patient-reported data collected upon clinic attendance. Factors contributing to patient inaccuracy were explored. Results: Of 341 patients providing initial data, 255 attended; 207 as appointments and 48 ‘walk-in’. The accuracy of patient-reported waiting times overall was 52% (133/255). 85% of patients (216/255) correctly identified themselves as seen within or outside of 48 hours. 17% of patients (17/103) seen within 48 hours reported a longer waiting period, whereas 20% of patients (22/108) reporting waits under 48 hours were seen outside that period. Men were more likely to overestimate their waiting time (10.4% versus 3.1% p<0.02). The sensitivity of patient-completed questionnaires as a tool for assessing waiting times of less than 48 hours was 83.5%. The specificity and positive predictive value were 85.5% and 79.6%, respectively. Conclusion: The overall accuracy of patient reported waiting times was poor. Although nearly one in six patients misclassified themselves as being seen within or outside of 48 hours, given the under and overreporting rates observed, the overall impact on Health Protection Agency waiting time data is likely to be limited

The public health importance of scabies in community domiciliary care settings: an exploratory cross-sectional survey of health protection teams in England

Scabies is a contagious skin infection commonly occurring in institutions such as care homes. However, a large proportion of vulnerable people in England receive domiciliary care in the community and their experience of scabies has not been described. We undertook a pragmatic cross-sectional survey of Health Protection Teams (HPTs) in England to determine the burden of scabies related to domiciliary care. Fifteen cases or outbreaks were notified to HPTs between January 2013 and December 2017. Although a relatively uncommon event for individual HPTs, they were complex to manage and required the co-ordination of multiple stakeholders. Diagnosis was often delayed and required several clinical consultations. A lack of guidance led to difficulties establishing stakeholder roles and responsibilities and sources of funding for treatment. The stigmatisation of scabies sometimes affected the quality of care provided to patients, such as use of excessive personal protective equipment. Our study demonstrates that scabies is an issue of public health importance for domiciliary care service providers and users, and research is required to better understand the impacts of the disease and to develop evidence-based guidance. More generally, there is a need for simpler treatment regimens and methods of diagnosing scabies

ADEPT for Secondary Payloads

Deployable entry vehicles provide an enabling capability for large payloads at destinations across the solar system. The primary advantage of such systems derives from the fundamental limitation of available launch vehicle shroads preventing tried-and-true rigid aeroshell technology from being applied. However, little mission-pull exists for deployable entry vehicle technology for missions where the entry vehicle is the primary payload and can fit within available shrouds. The propensity toward applying rigid aeroshell technology is logical given that deployable concepts are higher risk and provide no marginal scientific benefit for missions where a rigid aeroshell is an option. A movement toward flying smaller spacecraft has emerged in recent years and is revealing novel applications for deployable entry vehicles as secondary payloads. Secondary payloads must minimize interference with the primary payload in order to ease accomodation. Advancements in small spacecraft technology have caught the attention of government entities who are now recognizing the high value proposition of small spacecraft for frequent, incremental technology development and science return rather than the traditional high cost and infrequent big-bang approaches. Worldwide, well over 200 small satellites (mass < 180 kg) have launched in recent years for such purposes as eduation, technology development, science, commerce, and defense. The Adaptable Deployable Entry and Placement Technology (ADEPT), a mechanically-deployable entry vehicle technology, has been under development at NASA since 2011. An Ames Center Innovation Fund (CIF) proposal was recently awarded to study ADEPT for EDL of small payloads. The unique capability of ADEPT for small science payloads comes from its ability to stow within a slender volume and deploy passively to achieve a mass-efficient drag surface with a high heat rate capability. The low ballistic coefficient results in entry heating and mechanical loads that can be met by a revolutionary three-dimensionally woven carbon fabric supported with rib structures. This carbon fabric has test-proven capability as both primary structure and payload thermal protection. This presentation will inform the EDL community of the capability of ADEPT for delivery of small secondary payloads as well as provide status of on-going technology development activities. Results of a mission applications study for secondary payloads to Mars and Venus will be presented. A primary goal of these mission design activities is to integrate high-value verification approaches wherever possible. For example, for some mission applications it is possible to test in NASA arc jet facilities at full-scale. This enables endto- end thermostructural requirement verification with a single test. Another important challenge that needs to be solved is the reliability of the decelerator to achieve the desired shape using simple passive mechanical actuators (such as springs) that do not require power from the primary payload for deployment. A configuration of ADEPT is being prototyped and used to evaluate the functionality and reliability of the deployment mechanism through bench-top testing. The prototype will then be tested in a low speed wind tunnel in late 2014 to evaluate aerodynamic load-carrying capability and deflected shape. Results of the deployment testing and status of wind tunnel test plans will be discussed

Cost Effectiveness of Bio-Gas Systems for Dairy Farms

Considerable attention has recently been focused on the development of farm management practices that utilize the total resource potential of animal wastes. In addition to the fertilizer value of manure, energy in the form of bio-gas can be generated from manure wastes by an anaerobic digestion process. The purpose of this economic analysis was to evaluate the feasibility of producing energy from the anaerobic digestion of dairy-cow manure. Anaerobic digestion systems were rationally designed for several farm management practices on Vermont dairy farms. These designs were sized to accommodate dairy herds of 20, 50, 100, and 200 cows for both free- and tie-stall arrangements. The realistic evaluation of the potential of any energy source must include a cost effectiveness analysis. This 1974 economic analysis, with selected 1977 cost updatings, included considerations of both the total annual financial investment and the unit cost of net energy production. Minimum unit costs of net energy production for 1977 prices are approximately $0.19 per kwh for the 20-cow operation, but these values decrease with increasing herd size to$0.05 per kwh for the 200-cow dairy farm. At the present time, the generation of bio-gas from the anaerobic digestion of dairy farm manures becomes economically feasible as an alternate source of energy for dairy farms in excess of 200 cows

Enabling Entry Technologies for Ice Giant Missions

The highest priority science goals for Ice Giant missions are: 1) Interior structure of the Planet, and 2) Bulk composition that includes isotopes and noble gases. The interaction between the planetary interior and the atmosphere requires sustained global measurements. Noble gas and Isotope measurements require in situ measurement. Drag modulated aerocapture utilizing ADEPT offers more mass delivered to the Ice Giants than with propulsive orbit insertion. The Galileo Probe entered at a hot spot which created interpretation challenges. Juno is providing valuable orbital measurements, but without in situ measurements the story is incomplete. Planetary scientists interested in Ice Giant missions should perform mission design studies with these new Entry System technologies to assess the feasibility within the context of the international collaboration framework. A mission architecture that includes probe(s) along with an orbiting spacecraft can deploy the probes at the desired location while taking simultaneous measurements from orbit to provide invaluable data that can correlate both global and local measurements. Entry System Technologies currently being developed by NASA are poised to enable missions that position the Orbiter & Probes through drag modulated aerocapture (ADEPT), and HEEET enables the Probes to survive the extreme environments encountered for entry into the atmospheric interior

Exploring the costs and outcomes of sexually transmitted infection (STI) screening interventions targeting men in football club settings: preliminary cost-consequence analysis of the SPORTSMART pilot randomised controlled trial

Background: The objective of this study was to compare the costs and outcomes of two sexually transmitted infection (STI) screening interventions targeted at men in football club settings in England, including screening promoted by team captains. Methods: A comparison of costs and outcomes was undertaken alongside a pilot cluster randomised control trial involving three trial arms: (1) captain-led and poster STI screening promotion; (2) sexual health advisor-led and poster STI screening promotion and (3) poster-only STI screening promotion (control/comparator). For all study arms, resource use and cost data were collected prospectively. Results: There was considerable variation in uptake rates between clubs, but results were broadly comparable across study arms with 50% of men accepting the screening offer in the captain-led arm, 67% in the sexual health advisor-led arm and 61% in the poster-only control arm. The overall costs associated with the intervention arms were similar. The average cost per player tested was comparable, with the average cost per player tested for the captain-led promotion estimated to be £88.99 compared with £88.33 for the sexual health advisor-led promotion and £81.87 for the poster-only (control) arm. Conclusions: Costs and outcomes were similar across intervention arms. The target sample size was not achieved, and we found a greater than anticipated variability between clubs in the acceptability of screening, which limited our ability to estimate acceptability for intervention arms. Further evidence is needed about the public health benefits associated with screening interventions in non-clinical settings so that their cost-effectiveness can be fully evaluated

Primary care consultations and costs among HIV-positive individulas in UK primary care 1995-2005: a cohort study

Objectives: To investigate the role of primary care in the management of HIV and estimate primary care-associated costs at a time of rising prevalence. Methods: Retrospective cohort study between 1995 and 2005, using data from general practices contributing data to the UK General Practice Research Database. Patterns of consultation and morbidity and associated consultation costs were analysed among all practice-registered patients for whom HIV-positive status was recorded in the general practice record. Results: 348 practices yielded 5504 person-years (py) of follow-up for known HIV-positive patients, who consult in general practice frequently (4.2 consultations/py by men, 5.2 consultations/py by women, in 2005) for a range of conditions. Consultation rates declined in the late 1990s from 5.0 and 7.3 consultations/py in 1995 in men and women, respectively, converging to rates similar to the wider population. Costs of consultation (general practitioner and nurse, combined) reflect these changes, at £100.27 for male patients and £117.08 for female patients in 2005. Approximately one in six medications prescribed in primary care for HIV-positive individuals has the potential for major interaction with antiretroviral medications. Conclusion: HIV-positive individuals known in general practice now consult on a similar scale to the wider population. Further research should be undertaken to explore how primary care can best contribute to improving the health outcomes of this group with chronic illness. Their substantial use of primary care suggests there may be potential to develop effective integrated care pathways

Enabling Entry Technologies for Ice Giant Missions

The proposed poster will highlight two NASA developed entry technologies that are enablers for Ice Giant Missions. They are: (1) Heat-shield for Extreme Entry Environment Technology (HEEET), and (2) Adaptable, Deployable, Entry, and Placement Technology (ADEPT), a mechanically deployable entry system. HEEET development is complete and is at TRL 6. HEEET is ready for Ice Giant in situ probe missions, and HEEET is an enabler for either direct ballistic entry or entry from Orbit. NASA plans to sustain the HEEET capability as it is needed for Venus, Saturn and higher speed sample return missions in addition to Ice Giant Missions. The emerging recognition among the scientific community that by delivering the probe from orbit will allow for simultaneous in-situ and orbital measurement can be enabled by aerocapture using ADEPT. The drag modulated aerocapture (DMA) with ADEPT is the simplest approach that can deliver an orbiter and probe together and without the significant penalty associated with propulsive insertion. Studies performed by JPL and NASA Ames teams point to this very promising possibility. Numerous DMA with ADEPT studies point to its applicability to small spacecraft missions as well as Ice Giant missions. The poster will present the current state of readiness of HEEET, ADEPT and DMA

Optimising use of electronic health records to describe the presentation of rheumatoid arthritis in primary care: a strategy for developing code lists

Background Research using electronic health records (EHRs) relies heavily on coded clinical data. Due to variation in coding practices, it can be difficult to aggregate the codes for a condition in order to define cases. This paper describes a methodology to develop ‘indicator markers’ found in patients with early rheumatoid arthritis (RA); these are a broader range of codes which may allow a probabilistic case definition to use in cases where no diagnostic code is yet recorded. Methods We examined EHRs of 5,843 patients in the General Practice Research Database, aged ≥30y, with a first coded diagnosis of RA between 2005 and 2008. Lists of indicator markers for RA were developed initially by panels of clinicians drawing up code-lists and then modified based on scrutiny of available data. The prevalence of indicator markers, and their temporal relationship to RA codes, was examined in patients from 3y before to 14d after recorded RA diagnosis. Findings Indicator markers were common throughout EHRs of RA patients, with 83.5% having 2 or more markers. 34% of patients received a disease-specific prescription before RA was coded; 42% had a referral to rheumatology, and 63% had a test for rheumatoid factor. 65% had at least one joint symptom or sign recorded and in 44% this was at least 6-months before recorded RA diagnosis. Conclusion Indicator markers of RA may be valuable for case definition in cases which do not yet have a diagnostic code. The clinical diagnosis of RA is likely to occur some months before it is coded, shown by markers frequently occurring ≥6 months before recorded diagnosis. It is difficult to differentiate delay in diagnosis from delay in recording. Information concealed in free text may be required for the accurate identification of patients and to assess the quality of care in general practice

A Study of the Formation of Single- and Double-Walled Carbon Nanotubes by a CVD Method

The reduction in H2/CH4 atmosphere of aluminum-iron oxides produces metal particles small enough to catalyze the formation of single-walled carbon nanotubes. Several experiments have been made using the same temperature profile and changing only the maximum temperature (800-1070 °C). Characterizations of the catalyst materials are performed using notably 57Fe Mo¨ssbauer spectroscopy. Electron microscopy and a macroscopical method are used to characterize the nanotubes. The nature of the iron species (Fe3+, R-Fe, ç-Fe-C, Fe3C) is correlated to their location in the material. The nature of the particles responsible for the high-temperature formation of the nanotubes is probably an Fe-C alloy which is, however, found as Fe3C by postreaction analysis. Increasing the reduction temperature increases the reduction yield and thus favors the formation of surface-metal particles, thus producing more nanotubes. The obtained carbon nanotubes are mostly single-walled and double-walled with an average diameter close to 2.5 nm. Several formation mechanisms are thought to be active. In particular, it is shown that the second wall can grow inside the first one but that subsequent ones are formed outside. It is also possible that under given experimental conditions, the smallest (<2 nm) catalyst particles preferentially produce double-walled rather than single-walled carbon nanotubes