Judgement Analysis of Patient Management: General Practitioners' Policies and Self-Insight.

In this thesis judgement analysis (multiple linear regression techniques) was used to look at both GPs' decisions to prescribe certain types of drug for patients and their judgements of patients' risk of coronary heart disease. All of these were idiographic analyses in that decision making by each GP was modelled separately. Judgement analysis (paramorphically) describes a subject's judgement or decision making policy in terms of the relative influence of different pieces of information. The amount of information subjects could take into account was limited. For all types of judgement or decision doctors were influenced on average by only four of the thirteen or twelve cues available. The decision to prescribe one of the types of drug was modelled not only in terms of the individual effects of cues (judgement analysis) but also in terms of the influence of the doctor's assessment of the patient's risk. Doctors agreed more about judgements of risk and the factors influencing this than about prescription. Doctors only prescribed to patients they rated as at high risk but factors such as for example smoking behaviour led some doctors not to prescribe to individuals in this group. Judgement and decision making policies (explicit policies) were also elicited verbally from doctors. These showed greater agreement than the policies captured using judgement analysis (tacit policies) did. When these explicit policies were compared to tacit policies a moderate amount of correspondence was found. However, doctors tended to over-rate the importance of certain cues. A number of explanations for this pattern of self-insight were investigated including the possibilities that doctors have self-insight but are unable to state it and that the pattern was an artefact of linear modelling. Both of these hypotheses were rejected. Subjects' explicit policies were found to resemble the pattern of selection of information more than the pattern of its use. Both the hypotheses that subjects' explicit policies were based on phenomenal knowledge and that they are based on some ideal model (influencing which cues are selected) were supported

Supporting the uptake of resilient repair in the recovery process (FD2706)

Executive SummaryThis Defra research project (FD2706) was concerned with how the professionals and organisations involved in the recovery process following a flood incident interact with householders and business owners. In particular, the way in which decisions are made about reinstatement was examined, as there is a need to improve the understanding of the opportunities within the process for encouraging resilient repair. Resilient repair is the application of property flood resilience measures during the recovery period so that, should there be another flood, the householder or business owner can re-occupy their properties more quickly, which has well documented benefits. Installing some measures during recovery has also been shown to be more cost effective and potentially less disruptive than the retrofitting of measures at other times.The project had three elements: a quick scoping review; a series of case studies involving in-depth interviews with flooded households, small/micro-businesses and their repair networks; and, a series of facilitated group discussions with stakeholders to validate the findings of the Quick Scoping Review and case studies. Flow charts of the on-site and off-site processes and of the decisions involved in the repair of insured properties were developed to highlight the main points at which the ‘resilience’ of the reinstatement is determined. A list of 55 barriers and facilitators and a further list of 49 suggestions for change or wider application of good practice were extracted from the literature and interviews. Themes for improvement were developed and a selection of the suggestions was further explored in the facilitated group discussions.This document summarises all three elements of the project. The detailed findings of the Quick Scoping Review are also available in a separate report. Detailed findings from the in-depth interviews and workshops are available as appendices to this report

The DDX6-4E-T interaction mediates translational repression and P-body assembly.

4E-Transporter binds eIF4E via its consensus sequence YXXXXLΦ, shared with eIF4G, and is a nucleocytoplasmic shuttling protein found enriched in P-(rocessing) bodies. 4E-T inhibits general protein synthesis by reducing available eIF4E levels. Recently, we showed that 4E-T bound to mRNA however represses its translation in an eIF4E-independent manner, and contributes to silencing of mRNAs targeted by miRNAs. Here, we address further the mechanism of translational repression by 4E-T by first identifying and delineating the interacting sites of its major partners by mass spectrometry and western blotting, including DDX6, UNR, unrip, PAT1B, LSM14A and CNOT4. Furthermore, we document novel binding between 4E-T partners including UNR-CNOT4 and unrip-LSM14A, altogether suggesting 4E-T nucleates a complex network of RNA-binding protein interactions. In functional assays, we demonstrate that joint deletion of two short conserved motifs that bind UNR and DDX6 relieves repression of 4E-T-bound mRNA, in part reliant on the 4E-T-DDX6-CNOT1 axis. We also show that the DDX6-4E-T interaction mediates miRNA-dependent translational repression and de novo P-body assembly, implying that translational repression and formation of new P-bodies are coupled processes. Altogether these findings considerably extend our understanding of the role of 4E-T in gene regulation, important in development and neurogenesis.BBSRC [BB/J00779X/1 to N.S.]; CNRS PICS (to D.W.); Agence Nationale pour la Recherche [ANR-14-CE09-0013-01ANR to D.W.]; Gates Cambridge Foundation (to A.K.); Fondation Wiener – Anspach of the Université Libre de Bruxelles and the Cambridge Newton Trust (C.V.). Funding for open access charge: BBSRC

A Synthetic 21-cm Galactic Plane Survey of an SPH Galaxy Simulation

We have created synthetic neutral hydrogen (HI) Galactic Plane Survey data cubes covering 90 degrees < l < 180 degrees, using a model spiral galaxy from SPH simulations and the radiative transfer code TORUS. The density, temperature and other physical parameters are fed from the SPH simulation into TORUS, where the HI emissivity and opacity are calculated before the 21-cm line emission profile is determined. Our main focus is the observation of Outer Galaxy `Perseus Arm' HI, with a view to tracing atomic gas as it encounters shock motions as it enters a spiral arm interface, an early step in the formation of molecular clouds. The observation of HI self-absorption features at these shock sites (in both real observations and our synthetic data) allows us to investigate further the connection between cold atomic gas and the onset of molecular cloud formation.Comment: MNRAS accepted; 11 pages, 12 figure

The structure of HI in galactic disks: Simulations vs observations

We generate synthetic HI Galactic plane surveys from spiral galaxy simulations which include stellar feedback processes. Compared to a model without feedback we find an increased scale height of HI emission (in better agreement with observations) and more realistic spatial structure (including supernova blown bubbles). The synthetic data show HI self-absorption with a morphology similar to that seen in observations. The density and temperature of the material responsible for HI self-absorption is consistent with observationally determined values, and is found to be only weakly dependent on absorption strength and star formation efficiency.Comment: 12 pages, 7 figures. Accepted for publication in MNRA

A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health Science Network (EAHSN) model

Aims: We developed a new clinical integrated pathway linking a regional Ambulance Trust with a severe hypoglycaemia (SH) prevention team. We present clinical data from the first 2,000 emergency calls taken through this new clinical pathway in the East of England. Methods: SH patients attended by Ambulance crew receive written information on SH avoidance, and are contacted for further education through a new regional SH prevention team. All patients are contacted unless they actively decline. Results: Median age (IQR) was 67 (50 - 80) years, 23.6% of calls were for patients over 80 years old, and patients more than 90 years old were more common than 20 - 25 year olds in this population. Most calls were for patients (84.9%) who were insulin treated, even those over 80 years (75%). One - third of patients attended after a call were unconscious on attendance. 5.6% of patients in this call population had 3 or more ambulance call outs, and they generated 17.6% of all calls. In total, 728 episodes (36.4%) were repeat calls. Insulin related events were clinically more severe than oral hypoglycaemic related events. Patients conveyed to hospitals (13.8%) were significantly older, with poorer recovery in biochemical hypoglycaemia after ambulance crew attendance. Only 19 (1%) opted out of further contact. Patients were contacted by the SH prevention team after a median 3 (0 - 6) days. The most common patient self - reported cause for their SH episode was related to percieved errors in insulin management (31.4%). Conclusions: This new clinical service is simple, acceptable to patients, and a translatable model for prevention of recurrent SH in this largely elderly insulin treated SH population

Community-based pre-pregnancy care programme improves pregnancy preparation in women with pregestational diabetes.

AIMS/HYPOTHESIS: Women with diabetes remain at increased risk of adverse pregnancy outcomes associated with poor pregnancy preparation. However, women with type 2 diabetes are less aware of and less likely to access pre-pregnancy care (PPC) compared with women with type 1 diabetes. We developed and evaluated a community-based PPC programme with the aim of improving pregnancy preparation in all women with pregestational diabetes. METHODS: This was a prospective cohort study comparing pregnancy preparation measures before and during/after the PPC intervention in women with pre-existing diabetes from 1 June 2013 to 28 February 2017. The setting was 422 primary care practices and ten National Health Service specialist antenatal diabetes clinics. A multifaceted approach was taken to engage women with diabetes and community healthcare teams. This included identifying and sending PPC information leaflets to all eligible women, electronic preconception care templates, online education modules and resources, and regional meetings and educational events. Key outcomes were preconception folic acid supplementation, maternal HbA1c level, use of potentially harmful medications at conception and gestational age at first presentation, before and during/after the PPC programme. RESULTS: A total of 306 (73%) primary care practices actively participated in the PPC programme. Primary care databases were used to identify 5075 women with diabetes aged 18-45 years. PPC leaflets were provided to 4558 (89.8%) eligible women. There were 842 consecutive pregnancies in women with diabetes: 502 before and 340 during/after the PPC intervention. During/after the PPC intervention, pregnant women with type 2 diabetes were more likely to achieve target HbA1c levels ≤48 mmol/mol (6.5%) (44.4% of women before vs 58.5% of women during/after PPC intervention; p = 0.016) and to take 5 mg folic acid daily (23.5% and 41.8%; p = 0.001). There was an almost threefold improvement in 'optimal' pregnancy preparation in women with type 2 diabetes (5.8% and 15.1%; p = 0.021). Women with type 1 diabetes presented for earlier antenatal care during/after PPC (54.0% vs 67.3% before 8 weeks' gestation; p = 0.003) with no other changes. CONCLUSIONS/INTERPRETATION: A pragmatic community-based PPC programme was associated with clinically relevant improvements in pregnancy preparation in women with type 2 diabetes. To our knowledge, this is the first community-based PPC intervention to improve pregnancy preparation for women with type 2 diabetes. DATA AVAILABILITY: Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/our-clinical-audits-and-registries/national-pregnancy-in-diabetes-audit

Mortality benefits of population-wide adherence to national physical activity guidelines: a prospective cohort study

We quantified the mortality benefits and attributable fractions associated with engaging in physical activity across a range of levels, including those recommended by national guidelines. Data were from the Allied Dunbar National Fitness Survey, a population-based prospective cohort comprising 1,796 male and 2,122 female participants aged 16-96 years, randomly selected from 30 English constituencies in 1990. Participants were tagged for mortality at the Office for National Statistics. Cox multivariable regression quantified the association between self-reported achievement of activity guidelines--150 min of at least moderate activity per week, equivalent here to 30 or more 20-min episodes of at least moderate activity per month--and mortality adjusting for age, sex, smoking status, social class, geographical area, anxiety/depression and interview season. There were 1,175 deaths over a median (IQR) of 22.9 (3.9) years follow-up; a mortality rate of 15.2, 95% confidence interval (CI) 14.4-16.1 per 1,000 person years. Compared with being inactive (no 20-min bouts per month), meeting activity guidelines (30+ bouts) was associated with a 25% lower mortality rate, adjusting for measured confounders. If everyone adhered to recommended-, or even low-activity levels, a substantial proportion of premature mortality might be avoided (PAF, 95% CI 20.6, 6.9-32.3 and 8.9, 4.2-13.4%, respectively). Among a representative English population, adherence to activity guidelines was associated with significantly reduced mortality. Efforts to increase population-wide activity levels could produce large public health benefits and should remain a focus of health promotion efforts.The Allied Dunbar National Fitness Survey was funded by the Department of Health, Health Education Authority, The Sports Council and Allied Dunbar Assurance plc. This work was supported by the Medical Research Council (MC_UU_12015/1, MC_UU_12015/3 and MC_UU_12015/4). The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the UK Department of Health.This is the final published version. It first appeared at http://link.springer.com/article/10.1007%2Fs10654-014-9965-5

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research