The impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital

Background Emergency hospital admission at weekends is associated with an increased risk of mortality. Previous studies have been limited to examining single years and assessing day – not time – of admission. We used an enhanced longitudinal dataset to estimate the ‘weekend effect’ over time and the effect of night-time admission on the mortality rate. Method We examined 246,350 emergency spells from a large teaching hospital in England between April 2004 and March 2014. Outcomes included 7-day, 30-day and in-hospital mortality rates. We conducted probit regressions to estimate the impact of two key predictors on mortality: i) admission at weekends (7.00 pm Friday to 6.59 am Monday); ii) night-time admission (7.00 pm to 6.59 am). Logistic regressions were estimated to produce odds ratios. Results Crude 30-day mortality rate decreased from 6.6% in 2004/05 to 5.2% in 2013/14. Adjusted mortality risk was elevated for all out-of-hours periods. The highest risk was associated with admission at weekend night-times: 30-day mortality increased by 0.6 percentage points (adjusted OR: 1.168), 7-day mortality by 0.4 percentage points (adjusted OR: 1.225), and in-hospital mortality by 0.5 percentage points (adjusted OR: 1.140) compared with admission on weekday day-times. Weekend night-time admission was associated with increased mortality risk in 9 out of 10 years, but this was only statistically significant (P≤ 0.05) in 5 out of 10 years. Conclusions There is an increased risk of mortality for patients admitted as emergencies both at weekends and during the night-time. These effects are additive, so that the greatest risk of mortality occurs in patients admitted during the night at weekends. This increased risk appears to be consistent over time, but the effects are small and are not statistically significant in individual hospitals in every year

The effectiveness, safety and cost-effectiveness of cytisine versus varenicline for smoking cessation in an Australian population: a study protocol for a randomized controlled non-inferiority trial

Smoking cessation medications are effective but often underutilised because of costs and side effects. Cytisine is a plant-based smoking cessation medication with over 50 years of use in Central and Eastern Europe. While cytisine has been found to be well-tolerated and more effective than nicotine replacement therapy, direct comparison with varenicline have not been conducted. This study evaluates the effectiveness, safety and cost-effectiveness of cytisine compared with varenicline.Two arm, parallel group, randomised, non-inferiority trial, with allocation concealment and blinded outcome assessment.Australian population-based study.Adult daily smokers (N=1266) interested in quitting will be recruited through advertisements and Quitline telephone-based cessation support services.Eligible participants will be randomised (1:1 ratio) to receive either cytisine capsules (25-day supply) or varenicline tablets (12-week supply), prescribed in accordance with the manufacturer's recommended dosing regimen. The medication will be mailed to each participant's nominated residential address. All participants will also be offered standard Quitline behavioural support (up to six 10-12 minute sessions).Assessments will be undertaken by telephone at baseline, 4- and 7-months post-randomisation. Participants will also be contacted twice (two and four weeks post-randomisation) to ascertain adverse events, treatment adherence and smoking status. The primary outcome will be self-reported 6-month continuous abstinence from smoking, verified by carbon monoxide at 7-month follow-up. We will also evaluate the relative safety and cost-effectiveness of cytisine compared with varenicline. Secondary outcomes will include self-reported continuous and 7-day point prevalence abstinence and cigarette consumption at each follow-up interview.If cytisine is as effective as varenicline, its lower cost and natural plant-based composition may make it an acceptable and affordable smoking cessation medication that could save millions of lives worldwide

Bounding λ2 for Kähler–Einstein metrics with large symmetry groups

We calculate an upper bound for the second non-zero eigenvalue of the scalar Laplacian, λ2, for toric-Kähler–Einstein metrics in terms of the polytope data. We also give a similar upper bound for Koiso–Sakane type Kähler–Einstein metrics. We provide some detailed examples in complex dimensions 1, 2 and 3

Ground deformation analysis at Campi Flegrei (Southern Italy) by CGPS and tide-gauge network

Campi Flegrei caldera is located 15 km west of the city of Naples, within the central-southern sector of a large graben called Campanian Plain. It is an active volcanic area marked by a quasi-circular caldera depression, formed by a huge ignimbritic eruption occurred about 37000 years ago. This caldera was generated by several collapses produced by strong explosive eruptions (the last eruption, occurred in 1538, built an about 130 m spatter cone called Mt. Nuovo). Campi Flegrei area periodically experiences significant deformation episodes, with uplift phenomena up to more than 3.5 m in 15 years (from 1970 to 1984), which caused during 1983-84 the temporary evacuation of about 40000 people from the ancient part of Pozzuoli town. The deformation field obtainable by CGPS and tidegauge stations plays an important role for the modelling and interpretation of volcanic phenomena, as well as for forecasting purposes. The structural complexity of the Campi Flegrei area, together with the evidence of a strong interaction between magmatic chamber and shallow geothermal system, calls for a detailed characterization of the substructure and of magma-water interaction processes. The incoming experiment of deep drilling, down to about 4 km, will give detailed structural and physical constraints able to resolve the intrinsic ambiguities of geophysical data and in particular geodetic ones. In this poster we describe the recent ground deformations at Campi Flegrei area by means of GPS technique and tide gauge stations, discussing the possible interpretations also in light of further constraints likely coming from the next CFDDP (Campi Flegrei Deep Drilling) deep drilling experiment

Effect of point-of-care C-reactive protein testing on antibiotic prescription in febrile patients attending primary care in Thailand and Myanmar : an open-label, randomised, controlled trial

Background In southeast Asia, antibiotic prescription in febrile patients attending primary care is common, and a probable contributor to the high burden of antimicrobial resistance. The objective of this trial was to explore whether C-reactive protein (CRP) testing at point of care could rationalise antibiotic prescription in primary care, comparing two proposed thresholds to classify CRP concentrations as low or high to guide antibiotic treatment. Methods We did a multicentre, open-label, randomised, controlled trial in participants aged at least 1 year with a documented fever or a chief complaint of fever (regardless of previous antibiotic intake and comorbidities other than malignancies) recruited from six public primary care units in Thailand and three primary care clinics and one outpatient department in Myanmar. Individuals were randomly assigned using a computer-based randomisation system at a ratio of 1:1:1 to either the control group or one of two CRP testing groups, which used thresholds of 20 mg/L (group A) or 40 mg/L CRP (group B) to guide antibiotic prescription. Health-care providers were masked to allocation between the two intervention groups but not to the control group. The primary outcome was the prescription of any antibiotic from day 0 to day 5 and the proportion of patients who were prescribed an antibiotic when CRP concentrations were above and below the 20 mg/L or 40 mg/L thresholds. The primary outcome was analysed in the intention-to-treat and per-protocol populations. The trial is registered with ClinicalTrials.gov, number NCT02758821, and is now completed. Findings Between June 8, 2016, and Aug 25, 2017, we recruited 2410 patients, of whom 803 patients were randomly assigned to CRP group A, 800 to CRP group B, and 807 to the control group. 598 patients in CRP group A, 593 in CRP group B, and 767 in the control group had follow-up data for both day 5 and day 14 and had been prescribed antibiotics (or not) in accordance with test results (per-protocol population). During the trial, 318 (39%) of 807 patients in the control group were prescribed an antibiotic by day 5, compared with 290 (36%) of 803 patients in CRP group A and 275 (34%) of 800 in CRP group B. The adjusted odds ratio (aOR) of 0·80 (95% CI 0·65–0·98) and risk difference of −5·0 percentage points (95% CI −9·7 to −0·3) between group B and the control group were significant, although lower than anticipated, whereas the reduction in prescribing in group A compared with the control group was not significant (aOR 0·86 [0·70–1·06]; risk difference −3·3 percentage points [–8·0 to 1·4]). Patients with high CRP concentrations in both intervention groups were more likely to be prescribed an antibiotic than in the control group (CRP ≥20 mg/L: group A vs control group, p<0·0001; CRP ≥40 mg/L: group B vs control group, p<0·0001), and those with low CRP concentrations were more likely to have an antibiotic withheld (CRP <20 mg/L: group A vs control group, p<0·0001; CRP <40 mg/L: group B vs control group, p<0·0001). 24 serious adverse events were recorded, consisting of 23 hospital admissions and one death, which occurred in CRP group A. Only one serious adverse event was thought to be possibly related to the study (a hospital admission in CRP group A). Interpretation In febrile patients attending primary care, testing for CRP at point of care with a threshold of 40 mg/L resulted in a modest but significant reduction in antibiotic prescribing, with patients with high CRP being more likely to be prescribed an antibiotic, and no evidence of a difference in clinical outcomes. This study extends the evidence base from lower-income settings supporting the use of CRP tests to rationalise antibiotic use in primary care patients with an acute febrile illness. A key limitation of this study is the individual rather than cluster randomised study design which might have resulted in contamination between the study groups, reducing the effect size of the intervention

A 2018 Horizon Scan of Emerging Issues for Global Conservation and Biological Diversity.

This is our ninth annual horizon scan to identify emerging issues that we believe could affect global biological diversity, natural capital and ecosystem services, and conservation efforts. Our diverse and international team, with expertise in horizon scanning, science communication, as well as conservation science, practice, and policy, reviewed 117 potential issues. We identified the 15 that may have the greatest positive or negative effects but are not yet well recognised by the global conservation community. Themes among these topics include new mechanisms driving the emergence and geographic expansion of diseases, innovative biotechnologies, reassessments of global change, and the development of strategic infrastructure to facilitate global economic priorities