Factors associated with variation in hospital use at the end of life in England

Objective: To identify the relative importance of factors influencing hospital use at the end of life. Design: Retrospective cohort study of person and health system effects on hospital use in the past 12 months modelling differences in admissions, bed days and whether a person died in hospital. Setting: Residents in England for the period 2009/2010 to 2011/2012 using Hospital Episodes Statistics (HES) data from all acute care hospitals in England funded by the National Health Service (NHS). Participants: 1 223 859 people registered with a GP in England who died (decedents) in England (April 2009–March 2012) with a record of NHS hospital care. Main outcome measures: Hospital admissions, and hospital bed days and place of death (in or out of hospital) in the past 12 months of life. Results: The mean number of admissions in the past 12 months of life averaged 2.28 occupying 30.05 bed days—excluding 9.8% of patients with no hospital history. A total of 50.8% of people died in hospital. Difference in hospital use was associated with a range of patient descriptors (age, gender and ethnicity). The variables with the greatest ‘explanatory power’ were those that described the diagnoses and causes of death. So, for example, 65% of the variability in the model of hospital admissions was explained by diagnoses. Only moderate levels of variation were explained by the hospital provider variables for admissions and deaths in hospital, though the impacts on total bed days was large. Conclusions: Comparative analyses of hospital utilisation should standardise for a range of patient specific variables. Though the models indicated some degree of variability associated with individual providers, the scale of this was not great for admissions and death in hospital but the variability associated with length of stay differences suggests that attempts to optimise hospital use should look at differences in lengths of stay and bed use. This study adds important new information about variability in admissions by diagnostic group, and variability in bed days by diagnostic group and eventual cause of death

Comparing primary and secondary health-care use between diagnostic routes before a colorectal cancer diagnosis: Cohort study using linked data

BACKGROUND: Survival in cancer patients diagnosed following emergency presentations is poorer than those diagnosed through other routes. To identify points for intervention to improve survival, a better understanding of patients' primary and secondary health-care use before diagnosis is needed. Our aim was to compare colorectal cancer patients' health-care use by diagnostic route. METHODS: Cohort study of colorectal cancers using linked primary and secondary care and cancer registry data (2009-2011) from four London boroughs. The prevalence of all and relevant GP consultations and rates of primary and secondary care use up to 21 months before diagnosis were compared across diagnostic routes (emergency, GP-referred and consultant/other). RESULTS: The data set comprised 943 colorectal cancers with 24% diagnosed through emergency routes. Most (84%) emergency patients saw their GP 6 months before diagnosis but their symptom profile was distinct; fewer had symptoms meeting urgent referral criteria than GP-referred patients. Compared with GP-referred, emergency patients used primary care less (IRR: 0.85 (95% CI 0.78-0.93)) and urgent care more frequently (IRR: 1.56 (95% CI 1.12; 2.17)). CONCLUSIONS: Distinct patterns of health-care use in patients diagnosed through emergency routes were identified in this cohort. Such analyses using linked data can inform strategies for improving early diagnosis of colorectal cancer

In silico evaluation of WHO-endorsed molecular methods to detect drug resistant tuberculosis

Universal drug susceptibility testing (DST) for tuberculosis is a major goal of the END TB strategy. PCR-based molecular diagnostic tests have been instrumental in increasing DST globally and several assays have now been endorsed by the World Health Organization (WHO) for use in the diagnosis of drug resistance. These endorsed assays, however, each interrogate a limited number of mutations associated with resistance, potentially limiting their sensitivity compared to sequencing-based methods. We applied an in silico method to compare the sensitivity and specificity of WHO-endorsed molecular based diagnostics to the mutation set identified by the WHO mutations catalogue using phenotypic DST as the reference. We found that, in silico, the mutation sets used by probe-based molecular diagnostic tests to identify rifampicin, isoniazid, pyrazinamide, levofloxacin, moxifloxacin, amikacin, capreomycin and kanamycin resistance produced similar sensitivities and specificities to the WHO mutation catalogue. PCR-based diagnostic tests were most sensitive for drugs where mechanisms of resistance are well established and localised to small genetic regions or a few prevalent mutations. Approaches using sequencing technologies can provide advantages for drugs where our knowledge of resistance is limited, or where complex resistance signatures exist

Youth violence intervention programme for vulnerable young people attending emergency departments in London: a rapid evaluation

BACKGROUND: Youth violence intervention programmes involving the embedding of youth workers in NHS emergency departments to help young people (broadly aged between 11 and 24 years) improve the quality of their lives following their attendance at an emergency department as a result of violent assault or associated trauma are increasing across the NHS. This study evaluates one such initiative run by the charity Redthread in partnership with a NHS trust. OBJECTIVES: To evaluate the implementation and impact of a new youth violence intervention programme at University College London Hospital NHS Trust and delivered by the charity Redthread: (1) literature review of studies of hospital-based violent crime interventions; (2) evaluation of local implementation and of University College London Hospital staff and relevant local stakeholders concerning the intervention and its impact; (3) assessment of the feasibility of using routine secondary care data to evaluate the impact of the Redthread intervention; and (4) cost-effectiveness analysis of the Redthread intervention from the perspective of the NHS. METHODS: The evaluation was designed as a mixed-methods multiphased study, including an in-depth process evaluation case study and quantitative and economic analyses. The project was undertaken in different stages over two years, starting with desk-based research and an exploratory phase suitable for remote working while COVID-19 was affecting NHS services. A total of 22 semistructured interviews were conducted with staff at Redthread and University College London Hospital and others (e.g. a senior stakeholder involved in NHS youth violence prevention policy). We analysed Redthread documents, engaged with experts and conducted observations of staff meetings to gather more in-depth insights about the effectiveness of the intervention, the processes of implementation, staff perceptions and cost. We also undertook quantitative analyses to ascertain suitable measures of impact to inform stakeholders and future evaluations. RESULTS: Redthread's service was viewed as a necessary intervention, which complemented clinical and other statutory services. It was well embedded in the paediatric emergency department and adolescent services but less so in the adult emergency department. The diverse reasons for individual referrals, the various routes by which young people were identified, and the mix of specific support interventions provided, together emphasised the complexity of this intervention, with consequent challenges in implementation and evaluation. Given the relative unit costs of Redthread and University College London Hospital's inpatient services, it is estimated that the service would break even if around one-third of Redthread interventions resulted in at least one avoided emergency inpatient admission. This evaluation was unable to determine a feasible approach to measuring the quantitative impact of Redthread's youth violence intervention programme but has reflected on data describing the service, including costs, and make recommendations to support future evaluation. LIMITATIONS: The COVID-19 pandemic severely hampered the implementation of the Redthread service and the ability to evaluate it. The strongest options for analysis of effects and costs were not possible due to constraints of the consent process, problems in linking Redthread and University College London Hospital patient data and the relatively small numbers of young people having been engaged for longer-term support over the evaluation period. CONCLUSIONS: We have been able to contribute to the qualitative evidence on the implementation of the youth violence intervention programme at University College London Hospital, showing, for example, that NHS staff viewed the service as an important and needed intervention. In the light of problems with routine patient data systems and linkages, we have also been able to reflect on data describing the service, including costs, and made recommendations to support future evaluation. FUTURE WORK: No future work is planned. FUNDING: National Institute for Health and Care Research Health Services and Delivery Research programme (RSET: 16/138/17)

Thirty-two Goldbach Variations

We give thirty-two diverse proofs of a small mathematical gem--the fundamental Euler sum identity zeta(2,1)=zeta(3) =8zeta(\bar 2,1). We also discuss various generalizations for multiple harmonic (Euler) sums and some of their many connections, thereby illustrating both the wide variety of techniques fruitfully used to study such sums and the attraction of their study.Comment: v1: 34 pages AMSLaTeX. v2: 41 pages AMSLaTeX. New introductory material added and material on inequalities, Hilbert matrix and Witten zeta functions. Errors in the second section on Complex Line Integrals are corrected. To appear in International Journal of Number Theory. Title change

World citation and collaboration networks: uncovering the role of geography in science

Modern information and communication technologies, especially the Internet, have diminished the role of spatial distances and territorial boundaries on the access and transmissibility of information. This has enabled scientists for closer collaboration and internationalization. Nevertheless, geography remains an important factor affecting the dynamics of science. Here we present a systematic analysis of citation and collaboration networks between cities and countries, by assigning papers to the geographic locations of their authors' affiliations. The citation flows as well as the collaboration strengths between cities decrease with the distance between them and follow gravity laws. In addition, the total research impact of a country grows linearly with the amount of national funding for research & development. However, the average impact reveals a peculiar threshold effect: the scientific output of a country may reach an impact larger than the world average only if the country invests more than about 100,000 USD per researcher annually.Comment: Published version. 9 pages, 5 figures + Appendix, The world citation and collaboration networks at both city and country level are available at http://becs.aalto.fi/~rajkp/datasets.htm

APPLICATION OF VOLATILE FRACTIONS FROM AGERATUM HOUSTONIANUM AND TAGETES ERECTA AS SAFE MANAGEMENT OF SOME ROOT PHYTOPATOGENIC FUNGI

Ageratum houstonianum Mill and Tagetes erecta L. (Asteraceae) were subjected to hydrodis-tillation as well as the stepwise extraction with organic solvents. Crude extracts and the hydrodis-tilled essential oils (E.O) were bioevaluated against two phytopathogenic fungi Rhizoctonia solani and Phytophthora megasperma in vitro. The volatile fraction from both plants showed a good antifungal activity towards the tested fungi, EC50s were 91 and 1369 ppm for R. solani and 84 and 1571 ppm for P. megasperma with Ageratum essential oil (E.O) and Tagetes E.O, respectively. But generally; Ageratum E.O was found to be more effective in reducing mycelium growth of R. solani and P. megasperma (EC50 = 91 and 84 ppm respectively) than Tagetes E.O. Chemical compo-sition of Tagetes E.O and Ageratum E.O; fractions F1 (solid) and F2 (liquid) fractions were investi-gated by GC-MS analysis. Interestingly, heterocy-clic benzopyrane compound (Precocene II) was only component which has been detected in Ager-atum E.O fraction F1. Precocene II seems to be the fungitoxic active components in Ageratum E.O and its fractions. However, monoterpenic hydro-carbons were correlated with the fungitoxic effect of Tagetes E.O. In the green house experiments, Tagetes E.O and Ageratum E.O fraction F1 showed a clear selectivity towards tested patho-gens; Rhizoctonia solanii and Phytophthora megasperma. Ageratum E.O; fractions F1 was found to be much more fungitoxic activity than Tagetes E.O. Tagetes E.O and Ageratum E.O frac-tions F1 were controlled the 90.91% of Root-Rot disease in bean caused by Phytophthora megasperma, while the percentage of disease con-trol was only 36.36% for Rhizoctonia solani