Admission Decision-Making in Hospital Emergency Departments: the Role of the Accompanying Person

In resource-stretched emergency departments, people accompanying patients play key roles in patients' care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 healthcare professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals’ standardization of the patient-carer relationship contrasted with accompanying persons' varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients’ care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relations with patients. Taking a relationship-centered approach could improve attention to accompanying persons as co-producers of healthcare and participants in decision-making

An international assessment of the adoption of enhanced recovery after surgery (ERAS (R)) principles across colorectal units in 2019-2020

Aim The Enhanced Recovery After Surgery (ERAS (R)) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units. Method An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted. Results Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017. Conclusions Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation

Central K-band kinematics and line strength maps of NGC 1399

In this paper we present for the first time high spatial resolution K-band maps of the central kinematical and near-infrared spectral properties of the giant cD galaxy in the Fornax cluster, NGC 1399. We confirm the presence of a central velocity dispersion dip within radius < 0.2" seen in previous long-slit studies. Our velocity dispersion maps give evidence for a non-symmetric structure in this central area by showing three sigma peaks to the north-east, south-east and west of the galaxy centre. Additionally we measure near-IR line strength indices at unprecedented spatial resolution in NGC 1399. The most important features we observe in our 2-dimensional line strength maps are drops in Na I and CO(2-0) line strength in the nuclear region of the galaxy, coinciding spatially with the drop in sigma. The observed line strength and velocity dispersion changes suggest a scenario where the centre of NGC 1399 harbours a dynamically cold subsystem with a distinct stellar population.Comment: 9 pages, 5 figures, accepted for publication in A&

Ultraviolet Imaging Observations of the cD Galaxy in Abell 1795: Further Evidence for Massive Star Formation in a Cooling Flow

We present images from the Ultraviolet Imaging Telescope of the Abell 1795 cluster of galaxies. We compare the cD galaxy morphology and photometry of these data with those from existing archival and published data. The addition of a far--UV color helps us to construct and test star formation model scenarios for the sources of UV emission. Models of star formation with rates in the range \sim5-20M_{\sun}yr$^{-1}$ indicate that the best fitting models are those with continuous star formation or a recent ($\sim4$ Myr old) burst superimposed on an old population. The presence of dust in the galaxy, dramatically revealed by HST images complicates the interpretation of UV data. However, we find that the broad--band UV/optical colors of this cD galaxy can be reasonably matched by models using a Galactic form for the extinction law with $E_{B-V}=0.14$. We also briefly discuss other objects in the large UIT field of view.Comment: To appear in the Astrophysical Journal. 14 AAS preprint style pages plus 7 figure

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background: Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown. Aims: To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners. Methods: The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources. Findings: Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity. Conclusions: This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions. Funding: The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula

Cosmological Simulations with Scale-Free Initial Conditions I: Adiabatic Hydrodynamics

We analyze hierarchical structure formation based on scale-free initial conditions in an Einstein-de Sitter universe, including a baryonic component. We present three independent, smoothed particle hydrodynamics (SPH) simulations, performed with two different SPH codes (TreeSPH and P3MSPH) at two resolutions. Each simulation is based upon identical initial conditions, which consist of Gaussian distributed initial density fluctuations that have an n=-1 power spectrum. The baryonic material is modeled as an ideal gas subject only to shock heating and adiabatic heating and cooling. The evolution is expected to be self-similar in time, and under certain restrictions we identify the expected scalings for many properties of the distribution of collapsed objects in all three realizations. The distributions of dark matter masses, baryon masses, and mass and emission weighted temperatures scale quite reliably. However, the density estimates in the central regions of these structures are determined by the degree of numerical resolution. As a result, mean gas densities and luminosities obey the expected scalings only when calculated within a limited dynamic range in density contrast. The temperatures and luminosities of the groups show tight correlations with the baryon masses, which can be well-represented by power-laws. The Press-Schechter (PS) approximation predicts the distribution of group dark matter and baryon masses fairly well, though it tends to overestimate the baryon masses. Combining the PS mass distribution with the measured relations for T(M) and L(M) predicts the temperature and luminosity distributions reasonably, though there are some discrepancies at high temperatures/luminosities. The three simulations agree well for the properties of groups that are resolved by 32 or more particles.Comment: 40 pages, 16 embedded postscript figures, uses AASTEX 4.0 style. Minor wording changes, to appear in ApJ. Abridged abstrac

The impact of pre‐operative intravenous iron on quality of life after colorectal cancer surgery: outcomes from the intravenous iron in colorectal cancer‐associated anaemia (IVICA) trial

Anaemia is associated with a reduction in quality of life, and is common in patients with colorectal cancer . Werecently reported thefindings of the intravenous iron in colorectal cancer-associated anaemia (IVICA) trialcomparing haemoglobin levels and transfusion requirements following intravenous or oral iron replacement inanaemic colorectal cancer patients undergoing elective surgery. In this follow-up study, we compared theefficacy of intravenous and oral iron at improving quality of life in this patient group. We conducted amulticentre, open-label randomised controlled trial. Anaemic colorectal cancer patients were randomlyallocated at least two weeks pre-operatively, to receive either oral (ferrous sulphate) or intravenous (ferriccarboxymaltose) iron. We assessed haemoglobin and quality of life scores at recruitment, immediately beforesurgery and at outpatient review approximately three months postoperatively, using the Short Form 36,EuroQoL 5-dimension 5-level and Functional Assessment of Cancer Therapy–Anaemia questionnaires. Werecruited 116 anaemic patients across seven UK centres (oral iron n=61 (53%), and intravenous iron n=55(47%)). Eleven quality of life components increased by a clinically significant margin in the intravenous irongroup between recruitment and surgery compared with one component for oral iron. Median (IQR [range])visual analogue scores were significantly higher with intravenous iron at a three month outpatient review (oraliron 70, (60–85 [20–95]); intravenous iron 90 (80–90 [50–100]), p=0.001). The Functional Assessment ofCancer Therapy–Anaemia score comprises of subscales related to cancer, fatigue and non-fatigue itemsrelevant to anaemia. Median outpatient scores were higher, and hence favourable, for intravenous iron on theFunctional Assessment of Cancer Therapy–Anaemia subscale (oral iron 66 (55–72 [23–80]); intravenous iron 71(66–77 [46–80]); p=0.002), Functional Assessment of Cancer Therapy–Anaemia trial outcome index (oral iron108 (90–123 [35–135]); intravenous iron 121 (113–124 [81–135]); p=0.003) and Functional Assessment ofCancer Therapy–Anaemia total score (oral iron 151 (132–170 [69–183]); intravenous iron 168 (160–174 [125–186]); p=0.005). Thesefindings indicate that intravenous iron is more efficacious at improving quality of lifescores than oral iron in anaemic colorectal cancer patients

The uncoupling protein 1 gene, UCP1, is expressed in mammalian islet cells and associated with acute insulin response to glucose in African American families from the IRAS Family Study

BACKGROUND: Variants of uncoupling protein genes UCP1 and UCP2 have been associated with a range of traits. We wished to evaluate contributions of known UCP1 and UCP2 variants to metabolic traits in the Insulin Resistance and Atherosclerosis (IRAS) Family Study. METHODS: We genotyped five promoter or coding single nucleotide polymorphisms (SNPs) in 239 African American (AA) participants and 583 Hispanic participants from San Antonio (SA) and San Luis Valley. Generalized estimating equations using a sandwich estimator of the variance and exchangeable correlation to account for familial correlation were computed for the test of genotypic association, and dominant, additive and recessive models. Tests were adjusted for age, gender and BMI (glucose homeostasis and lipid traits), or age and gender (obesity traits), and empirical P-values estimated using a gene dropping approach. RESULTS: UCP1 A-3826G was associated with AIR(g )in AA (P = 0.006) and approached significance in Hispanic families (P = 0.054); and with HDL-C levels in SA families (P = 0.0004). Although UCP1 expression is reported to be restricted to adipose tissue, RT-PCR indicated that UCP1 is expressed in human pancreas and MIN-6 cells, and immunohistochemistry demonstrated co-localization of UCP1 protein with insulin in human islets. UCP2 A55V was associated with waist circumference (P = 0.045) in AA, and BMI in SA (P = 0.018); and UCP2 G-866A with waist-to-hip ratio in AA (P = 0.016). CONCLUSION: This study suggests a functional variant of UCP1 contributes to the variance of AIR(g )in an AA population; the plausibility of this unexpected association is supported by the novel finding that UCP1 is expressed in islets