Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network.

BACKGROUND: Internationally health services are facing increasing demands due to new and more expensive health technologies and treatments, coupled with the needs of an ageing population. Reducing avoidable use of expensive secondary care services, especially high cost admissions where no procedure is carried out, has become a focus for the commissioners of healthcare. METHOD: We set out to identify, evaluate and share learning about interventions to reduce avoidable hospital admission across a regional Academic Health and Social Care Network (AHSN). We conducted a service evaluation identifying initiatives that had taken place across the AHSN. This comprised a literature review, case studies, and two workshops. RESULTS: We identified three types of intervention: pre-hospital; within the emergency department (ED); and post-admission evaluation of appropriateness. Pre-hospital interventions included the use of predictive modelling tools (PARR - Patients at risk of readmission and ACG - Adjusted Clinical Groups) sometimes supported by community matrons or virtual wards. GP-advisers and outreach nurses were employed within the ED. The principal post-hoc interventions were the audit of records in primary care or the application of the Appropriateness Evaluation Protocol (AEP) within the admission ward. Overall there was a shortage of independent evaluation and limited evidence that each intervention had an impact on rates of admission. CONCLUSIONS: Despite the frequency and cost of emergency admission there has been little independent evaluation of interventions to reduce avoidable admission. Commissioners of healthcare should consider interventions at all stages of the admission pathway, including regular audit, to ensure admission thresholds don't change

Sickness Behaviors Across Vertebrate Taxa: Proximate and Ultimate Mechanisms

There is nothing like a pandemic to get the world thinking about how infectious diseases affect individual behavior. In this respect, sick animals can behave in ways that are dramatically different from healthy animals: altered social interactions and changes to patterns of eating and drinking are all hallmarks of sickness. As a result, behavioral changes associated with inflammatory responses (i.e. sickness behaviors) have important implications for disease spread by affecting contacts with others and with common resources, including water and/or sleeping sites. In this Review, we summarize the behavioral modifications, including changes to thermoregulatory behaviors, known to occur in vertebrates during infection, with an emphasis on non-mammalian taxa, which have historically received less attention. We then outline and discuss our current understanding of the changes in physiology associated with the production of these behaviors and highlight areas where more research is needed, including an exploration of individual and sex differences in the acute phase response and a greater understanding of the ecophysiological implications of sickness behaviors for disease at the population level

Identifying key controls on storm formation over the Lake Victoria Basin

The Lake Victoria region in East Africa is a hotspot for intense convective storms that are responsible for the deaths of thousands of fisherman each year. The processes responsible for the initiation, development and propagation of the storms are poorly understood and forecast skill is limited. Key processes for the lifecycle of two storms are investigated using Met Office Unified Model convection-permitting simulations with 1.5 km horizontal gridspacing. The two cases are analysed alongside a simulation of a period with no storms to assess the roles of the lake–land breeze, downslope mountain winds, prevailing large-scale winds and moisture availability. Whilst seasonal changes in large-scale moisture availability play a key role in storm development, the lake–land breeze circulation is a major control on the initiation location, timing and propagation of convection. In the dry season, opposing offshore winds form a bulge of moist air above the lake surface overnight that extends from the surface to ~1.5 km and may trigger storms in high CAPE/low CIN environments. Such a feature has not been explicitly observed or modelled in previous literature. Storms over land on the preceding day are shown to alter the local atmospheric moisture and circulation to promote storm formation over the lake. The variety of initiation processes and differing characteristics of just two storms analysed here show that the mean diurnal cycle over Lake Victoria alone is inadequate to fully understand storm formation. Knowledge of daily changes in local-scale moisture variability and circulations are key for skilful forecasts over the lake

Evaluation of the response of a vaulted masonry structure to differential settlements using point cloud data and limit analyses

Differential settlements have adverse effects on the serviceability and stability of vaulted masonry structures. However, the existing monitoring and assessment techniques do not capture these effects in sufficient detail. In this paper, a new approach is proposed to better describe the influence of support movements on barrel vaults. In this approach, laser scan point clouds of a settling vaulted structure are compared. Different cloud comparison methods are used to accurately identify the displacements of small point cloud segments. In particular, a new cloud comparison method, which modifies the well-known iterative closest point (ICP) registration algorithm, is developed. By constraining ICP to ensure displacement continuity between adjoining point cloud segments, three dimensional movement estimates of the structure are obtained. These estimates delineate the settlement response by indicating the location and magnitude of cracking. This rich information is then used to identify the settlement response mechanism of the vault using limit state numerical analysis. Finally, by interpreting the numerical results with relevant serviceability criteria, a new method to quantify the influence of settlements on barrel vaulted masonry structures is proposed. This damage assessment technique is used to evaluate observed damage due to piling-induced settlements in a masonry viaduct at London Bridge Station.The work carried out was funded by EPSRC and Innovate UK, through the Cambridge Centre for Smart Infrastructure and Construction (Grant Reference Number EP/L010917/1)

The effect of westerlies on East African rainfall and the associated role of tropical cyclones and the Madden–Julian Oscillation

Variability of rainfall in East Africa has major impacts on lives and livelihoods. From floods to droughts, this variability is important on short daily time‐scales to longer decadal time‐scales, as is apparent from the devastating effects of droughts in East Africa over recent decades. Past studies have highlighted the Congo airmass in enhancing East African rainfall. Our detailed analysis of the feature shows that days with a westerly moisture flow, bringing the Congo airmass, enhance rainfall by up to 100% above the daily mean, depending on the time of year. Conversely, there is a suppression of rainfall on days with a strong easterly flow. Days with a westerly moisture flux are in a minority in all seasons but we show that long rains with more westerly days are wetter, and that during the most‐recent decade which has had more frequent droughts (associated with the “Eastern African climate paradox”), there has been few days with such westerlies. We also investigate the influence of the Madden–Julian Oscillation (MJO) and tropical cyclones, and their interaction with the westerly flow. We show that days of westerly moisture flux are more likely during phases 3 and 4 of the MJO and when there are one or more tropical cyclones present. In addition, tropical cyclones are more likely to form during these phases of the MJO, and more likely to be coincident with westerlies when forming to the east of Madagascar. Overall, our analysis brings together many different processes that have been discussed in the literature but not yet considered in complete combination. The results demonstrate the importance of the Congo airmass on daily to climate time‐scales, and in doing so offers useful angles of investigation for future studies into prediction of East African rainfall

Mend the Gap: The Independent Review into Gender Pay Gaps in Medicine in England

The Independent Review into Gender Pay Gaps in Medicine in England was commissioned by the Department of Health and Social Care in 2017. It is the largest and most comprehensive review of its kind ever completed in the public sector. Chaired by Professor Dame Jane Dacre and led by Professor Carol Woodhams, the review takes a comprehensive approach to understanding the structural and cultural barriers affecting the female medical workforce

A Descriptive Analysis of the Temporal and Geographical Proximities Seen Within UK Series of Sex Offenses

Previous studies of the geographical and temporal features of serial sex offenses are limited by small samples and/or geographical areas, and are dated. We address a significant gap in the literature by investigating the temporal and geographical proximity of the crimes of 402 serial stranger sex offenders in the UK. Periods of incarceration were extracted from calculations of temporal proximity giving a more accurate picture of series duration and time elapsed between offenses from the same series. A notable minority of serial stranger sex offenders commit their offenses within very close geographic proximity and the same was found for temporal proximity. There were also occurrences of series spanning large distances and many years. The implications of these findings for the use of geography and time in the behavioral linking of crimes, and what they mean for policy decisions regarding financial investment in law enforcement technology, are discussed