The impact of delayed transfers of care on emergency departments: common sense arguments, evidence and confounding

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordData availability statement: All data and code required to reproduce this study are available at http://doi.org/10.5281/zenodo.3523179Objectives There have been claims that Delayed Transfers of Care (DTOCs) of inpatients to home or a less acute setting are related to Emergency Department (ED) crowding. In particular DTOCs were associated with breaches of the UK 4-hour waiting time target in a previously published analysis. However, the analysis has major limitations by not adjusting for the longitudinal trend of the data. The aim of this work is to investigate whether the proposition that DTOCs impact the 4-hour target requires further research. Method Estimation of an association between two or more variables that are measured over time requires specialised statistical methods. In this study, we performed two separate analyses. First, we created two sets of artificial data with no correlation. We then added an upward trend over time and again assessed for correlation. Second, we reproduced the simple linear regression of the original study using NHS England open data of English trusts between 2010 and 2016, assessing correlation of numbers of DTOCs and ED breaches of the 4-hour target. We then reanalysed the same data using standard time series methods to remove the trend before estimating an association. Results After introducing upward trends into the uncorrelated artificial data the correlation between the two data sets increased (R2=0.00 to 0.51 respectively). We found strong evidence of longitudinal trends within the NHS data of ED breaches and DTOCs. After removal of the trends the R2 reduced from 0.50 to 0.01. Conclusion Our reanalysis found weak correlation between numbers of DTOCs and ED 4-hour target breaches. Our study does not indicate that there is no relationship between 4-hour target and DTOCs, it highlights that statistically robust evidence for this relationship does not currently exist. Further work is required to understand the relationship between breaches of the 4-hour target and numbers of DTOCs.National Institute for Health Research (NIHR

The effects of two equal-volume training protocols upon strength, body composition and salivary hormones in male rugby union players

This study examined the effects of two equal-volume resistance-training protocols upon strength, body composition and salivary hormones in male rugby union players. Using a crossover design, 24 male rugby players completed a 4-week full-body (FB) and split-body (SB) training protocol of equal volume during the competitive season. One repetition maximum (1RM) strength, body composition via skinfold measurements and salivary testosterone (T) and cortisol (C) concentrations were assessed pre and post training. The FB and SB protocols improved upper (7.3% and 7.4%) and lower body 1RM strength (7.4% and 5.4%), whilst reducing body fat (-0.9% and -0.4%) and fat mass (-5.7% and -2.1%), respectively (all p ≤ 0.021). The SB protocol elevated T (21%) and C (50%) concentrations with a higher T/C ratio (28%) after FB training (all p ≤ 0.039). The strength changes were similar, but the body composition and hormonal results differed by protocol. Slope testing on the individual responses identified positive associations (p ≤ 0.05) between T and C concentrations and absolute 1RM strength in stronger (squat 1RM = 150.5 kg), but not weaker (squat 1RM = 117.4 kg), men. A short window of training involving FB or SB protocols can improve strength and body composition in rugby players. The similar strength gains highlight training volume as a key adaptive stimulus, although the programme structure (i.e. FB or SB) did influence the body composition and hormonal outcomes. It also appears that 1RM strength is associated with individual hormonal changes and baseline strength

Sex differences in the efficacy of psychological therapies for the management of chronic and recurrent pain in children and adolescents:a systematic review and meta-analysis

Sex differences in chronic pain are reported to emerge during adolescence, although it is unclear if this includes responses to treatment. We conducted a meta-analysis to examine whether sex differences were present on outcome variables at pre-treatment, and whether the efficacy of psychological therapies for pediatric chronic pain differs between boys and girls at post-treatment and follow-up time points. Searches were conducted, extending two existing Cochrane reviews of randomized-controlled trials examining the efficacy of psychological therapies for chronic and recurrent pain in children and adolescents. Forty-six articles were eligible for inclusion, and data were extracted regarding pain, disability, anxiety, and depression in boys and girls at pre-treatment, post-treatment, and follow-up time points. No published study reported outcome data separately by sex, so authors of all studies were contacted and 17 studies provided data. Twice as many girls (n =1760) were enrolled into clinical trials of psychological therapies for pediatric chronic pain than boys (n = 828). Girls reported higher depression and anxiety at pre-treatment than boys. Girls with headache also reported significantly greater pre-treatment pain severity. Treatment gains were consistent across the sexes. One exception was for post-treatment disability in children with non-headache pain conditions; girls exhibited a significant effect of treatment relative to control condition (SMD= -0.50[-0.80,-0.20], p &lt; .01), but no such effect was observed for boys (SMD= -0.08[-0.44,0.28], p = .66). Future research should examine whether mechanisms of treatment efficacy differ between boys and girls, and consider the impact of pre-treatment sex differences on response to treatment.</p

Pulmonary arterial hypertension: a new era in management

The document attached has been archived with permission from the editor of the Medical Journal of Australia. An external link to the publisher’s copy is included.Pulmonary arterial hypertension (PAH) is a heterogeneous condition with a wide range of causes. The diagnosis is often delayed or missed. PAH is covert in its early stages, when its detection and treatment should have the most impact. Access in Australia to effective PAH therapies has lagged behind that in other affluent countries. New agents for PAH, now becoming available, improve symptoms and reduce pulmonary resistance, with some demonstrating an ability to reverse remodelling of the right ventricle. Best management of PAH is comprehensive and multidisciplinary. Centres of excellence are needed in geographically strategic areas. Aggressive efforts must be made to diagnose PAH and to facilitate access to effective therapies.Anne M Keogh, Keith D McNeil, Trevor Williams, Eli Gabbay and Leslie G Clelan

Temporal progression of photosynthetic-strategy in phytoplankton in the Ross Sea, Antarctica

The bioavailability of iron influences the distribution, biomass and pioductivity of phytoplankton in the Ross Sea, one of the most productive regions in the Southern Ocean. We mapped the spatial and temporal extent and severity of iron-limitation of the native phytoplankton assemblage using long- (\u3e24 h) and short-term (24 h) iron-addition experiments along with physiological and molecular characterisations during a cruise to the Ross Sea in December February 2012. Phytoplankton increased their photosynthetic efficiency in response to iron addition, suggesting proximal iron limitation throughout most of the Ross Sea during summer. Molecular and physiological data further indicate that as nitrate is removed from the surface ocean the phytoplankton community transitions to one displaying an iron-efficient photosynthetic strategy characterised by an increase in the size of photosystem II (PSII) photochemical cross section (sigma(rpsII)) and a decrease in the chlorophyll-normalised PSII abundance. These results suggest that phytoplankton with the ability to reduce their photosynthetic iron requirements are selected as the growing season progresses, which may drive the well-documented progression from Phaeocystis antarctica- assemblages to diatom-dominated phytoplanlcton. Such a shift in the assemblage-level photosynthetic strategy potentially mediates further drawdown of nitrate following the development of iron deficient conditions in the Ross Sea

Discovering granger-causal features from deep learning networks

© Springer Nature Switzerland AG 2018. In this research, we propose deep networks that discover Granger causes from multivariate temporal data generated in financial markets. We introduce a Deep Neural Network (DNN) and a Recurrent Neural Network (RNN) that discover Granger-causal features for bivariate regression on bivariate time series data distributions. These features are subsequently used to discover Granger-causal graphs for multivariate regression on multivariate time series data distributions. Our supervised feature learning process in proposed deep regression networks has favourable F-tests for feature selection and t-tests for model comparisons. The experiments, minimizing root mean squared errors in the regression analysis on real stock market data obtained from Yahoo Finance, demonstrate that our causal features significantly improve the existing deep learning regression models

Measuring rates of present-day relative sea-level rise in low-elevation coastal zones: a critical evaluation

Although tide gauges are the primary source of data used to calculate multi-decadal- to century-scale rates of relative sea-level change, we question the usefulness of tide-gauge data in rapidly subsiding low-elevation coastal zones (LECZs). Tide gauges measure relative sea-level rise (RSLR) with respect to the base of associated benchmarks. Focusing on coastal Louisiana, the largest LECZ in the United States, we find that these benchmarks (n=35) are anchored an average of 21.5&thinsp;m below the land surface. Because at least 60&thinsp;% of subsidence occurs in the top 5&thinsp;m of the sediment column in this area, tide gauges in coastal Louisiana do not capture the primary contributor to RSLR. Similarly, global navigation satellite system (GNSS) stations (n=10) are anchored an average of &gt;&thinsp;14.3&thinsp;m below the land surface and therefore also do not capture shallow subsidence. As a result, tide gauges and GNSS stations in coastal Louisiana, and likely in LECZs worldwide, systematically underestimate rates of RSLR as experienced at the land surface. We present an alternative approach that explicitly measures RSLR in LECZs with respect to the land surface and eliminates the need for tide-gauge data in this context. Shallow subsidence is measured by rod surface-elevation table–marker horizons (RSET-MHs) and added to measurements of deep subsidence from GNSS data, plus sea-level rise from satellite altimetry. We show that for an LECZ the size of coastal Louisiana (25&thinsp;000–30&thinsp;000&thinsp;km2), about 40 RSET-MH instruments suffice to collect useful data. Rates of RSLR obtained from this approach are substantially higher than rates as inferred from tide-gauge data. We therefore conclude that LECZs may be at higher risk of flooding within a shorter time horizon than previously assumed.</p

Dairy Ingredients for Chocolate and Confectionery Products.

End of Project ReportHigh free-fat, spray-dried powders were successfully produced at a lower fat content (40% rather than 56%) using ultrafiltration. Chocolates made from these powders had improved flow properties and superior quality. The stability, viscosity and firmness of toffees were improved by optimising the casein, whey protein and lactose levels of skim milk powders used in their manufacture.Department of Agriculture, Food and the Marin

A Metabolomic Signature of Acute Caloric Restriction

Context: The experimental paradigm of acute caloric restriction followed by refeeding can be used to study the homeostatic mechanisms that regulate energy homeostasis, which are relevant to understanding the adaptive response to weight loss. Objective: Metabolomics, the measurement of hundreds of small molecule metabolites, their precursors, derivatives, and degradation products, has emerged as a useful tool for the study of physiology and disease and was used here to study the metabolic response to acute caloric restriction. Participants, Design and Setting: We used four ultra high performance liquid chromatography-tandem mass spectrometry methods to characterize changes in carbohydrates, lipids, amino acids and steroids in eight normal weight men at baseline, after 48 hours of caloric restriction (CR; 10% of energy requirements) and after 48 hours of ad libitum refeeding in a tightly-controlled environment. Results: We identified a distinct metabolomic signature associated with acute CR characterized by the expected switch from carbohydrate to fat utilization with increased lipolysis and beta-fatty acid oxidation. We found an increase in omega-fatty acid oxidation and levels of endocannabinoids which are known to promote food intake. These changes were reversed with refeeding. Several plasmalogen phosphatidylethanolamines (endogenous anti-oxidants) significantly decreased with CR (all p≤0.0007). Additionally, 48 acute CR was associated with an increase in the branched chain amino acids (all p≤1.4x10-7) and dehydroepiandrosterone sulfate (p=0.0006). Conclusions We identified a distinct metabolomic signature associated with acute CR. Further studies are needed to characterise the mechanisms that mediate these changes and their potential contribution to the adaptive response to dietary restriction.This work was supported by the Wellcome Trust (to I.S.F.), the NIHR Cambridge Biomedical Research Centre, the European Research Council, the Bernard Wolfe Health Neuroscience Fund (all to I.S.F.), the Swiss National Science Foundation (P3SMP3-155318, PZ00P3-167826, to T.H.C.), and the Uehara Memorial Foundation (to T.S.). This work was supported by the NIHR Rare Diseases Translational Research Collaboration and the NeuroFAST consortium, which is funded by the European Union’s Seventh Framework Programme (FP7/2007-2013) under grant agreement no 245009

The macro-economic effects of health co-benefits associated with climate change mitigation strategies

The UK government has specific targets for greenhouse gas (GHG) emission reduction to lower the risk of dangerous climate change. Strategies to reduce GHG emissions are sometimes perceived as expensive and difficult to implement but previous work has demonstrated significant potential health co-benefits from ‘Active Travel and low carbon driving’, ‘Housing Insulation/Ventilation’, and ‘Healthy Diet’ scenarios which may be attractive to policymakers. Here a Computable General Equilibrium model is used to assess the financial effects of such health co-benefits on the wider economy including changes in labour force, social security payments and healthcare costs averted. Results suggest that for all scenarios the financial impacts of the health co-benefits will be positive and increased active travel in particular is likely to make a substantial contribution, largely due to health care costs averted. Strategies to reduce GHG emissions and improve health are likely to result in substantial and increasing positive contributions to the economy which may offset some potential economic costs and thereby be seen more favourably in times of economic austerity