Risk of COVID-19 hospital admission and COVID-19 mortality during the first COVID-19 wave with a special emphasis on ethnic minorities: an observational study of a single, deprived, multiethnic UK health economy

© 2021 The Authors. Published by BMJ. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: http://dx.doi.org/10.1136/bmjopen-2020-046556Objectives The objective of this study was to describe variations in COVID-19 outcomes in relation to local risks within a well-defined but diverse single-city area. Design Observational study of COVID-19 outcomes using quality-assured integrated data from a single UK hospital contextualised to its feeder population and associated factors (comorbidities, ethnicity, age, deprivation). Setting/participants Single-city hospital with a feeder population of 228 632 adults in Wolverhampton. Main outcome measures Hospital admissions (defined as COVID-19 admissions (CA) or non-COVID-19 admissions (NCA)) and mortality (defined as COVID-19 deaths or non-COVID-19 deaths). Results Of the 5558 patients admitted, 686 died (556 in hospital); 930 were CA, of which 270 were hospital COVID-19 deaths, 47 non-COVID-19 deaths and 36 deaths after discharge; of the 4628 NCA, there were 239 in-hospital deaths (2 COVID-19) and 94 deaths after discharge. Of the 223 074 adults not admitted, 407 died. Age, gender, multimorbidity and black ethnicity (OR 2.1 (95% CI 1.5 to 3.2), p<0.001, compared with white ethnicity, absolute excess risk of <1/1000) were associated with CA and mortality. The South Asian cohort had lower CA and NCA, lower mortality compared with the white group (CA, 0.5 (0.3 to 0.8), p<0.01; NCA, 0.4 (0.3 to 0.6), p<0.001) and community deaths (0.5 (0.3 to 0.7), p<0.001). Despite many common risk factors for CA and NCA, ethnic groups had different admission rates and within-group differing association of risk factors. Deprivation impacted only the white ethnicity, in the oldest age bracket and in a lesser (not most) deprived quintile. Conclusions Wolverhampton’s results, reflecting high ethnic diversity and deprivation, are similar to other studies of black ethnicity, age and comorbidity risk in COVID-19 but strikingly different in South Asians and for deprivation. Sequentially considering population and then hospital-based NCA and CA outcomes, we present a complete single health economy picture. Risk factors may differ within ethnic groups; our data may be more representative of communities with high Black, Asian and minority ethnic populations, highlighting the need for locally focused public health strategies. We emphasise the need for a more comprehensible and nuanced conveyance of risk

Side effects of messenger RNA vaccines and prior history of COVID-19, a cross-sectional study

Background There are concerns regarding immunogenicity with coronavirus disease 2019 (COVID-19) mRNA vaccines among persons with prior history of COVID-19 (PHC). This study was to analyze the short-term side effects of mRNA vaccines among health care workers (HCWs) with and without PHC. Methods A cross-sectional study was performed using an independent online survey questionnaire that gathered responses from HCWs. Results Among 1,475 HCWs, 1268 (85.97%) completed the survey, 102/1268 (44/447 in Moderna group and 58/821 in Pfizer-BioNTech group) reported PHC during pre-vaccination period. Symptoms of flushing/P = .05, brain fogging/P= .005, vertigo/P= .041, numbness/P= .023, diarrhea/P= .047, hives/P= .028, itching/P= .028, swelling of lips/mouth/P= .001, shortness of breath/P= .022, and anxiety/P= .048 have greater occurrence among Pfizer-BioNtech group with PHC when compared to Pfizer-BioNtech group with no PHC. Symptoms of chills/P= .027, flushing/P= .045, tremor/P= .05, muscle spasm/P= .039, vomiting/P= .031, diarrhea/P= .015, and cough/P= .011 have higher occurrence among Moderna group with PHC when compared to Moderna group with no PHC. Conclusions Few short-term side effects among mRNA vaccine recipients with PHC may have necessitated transient time-off from work. The PHC can be considered as a predictor for severity of side effects. While the vaccination program continues in the United States, a future COVID legislation that mandates vaccination among employees along with paid time off provision may help with higher compliance and acceptance

Is annual surveillance of all treated hypothyroid patients necessary?

Peer reviewedPublisher PD

DETC2003/CIE-48260 RCS BASED HARDWARE-IN-THE-LOOP EMBEDDED CONTROL OF INDUSTRIAL STAMPING PROCESSES

ABSTRACT There is a growing need for providing a flexible mechatronic environment to enhance productivity in industrial processes. Specifically, in the area of sheet metal forming, where stamping quality and part consistency are still achieved by traditional iterative process of trial and error, there is a clear urgency to enhance productivity and quality through automation. The traditional feedback control schemes used in many industrial processes cannot be applied to sheet metal forming, mainly due to the complexity of the stamping process and associated difficulty of using COTS (off-the-shelf) controllers for such applications. In this paper we demonstrate a hardware-in-the-loop flexible mechatronic design environment that will allow batch production of stamped parts with varying geometry and material properties, with minimal defects and greater consistency, using Simulink/RTW/xpcTarget framework which affords the feature of open architecture controller and the NIST Real-time Control System (RCS) architecture that allows structured, hierarchical implementation of industrial controllers. In conjunction with the Neutral Message Language (NML) RCS also allows for distributed hardware-in-the-loop control design with multiple processors. The merits of this approach over conventional approaches are also highlighted. . INTRODUCTION The new mantra in manufacturing is agility and lean manufacturing. The ramifications of globalization have forced manufacturers in the forming and fabricating industry to adopt this new mantra. Two key aspects of agility and lean manufacturing are, knowledge modeling/sharing giving both captive and contract manufacturers the tools for collaborating in the product design and open architecture controllers promoting teamwork of operators and engineers without having to work with multiple controllers hanging on the press

Parathyroidectomy for adults with primary hyperparathyroidism

Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Review which updates 2018 protocol deposited in WIRE: http://hdl.handle.net/2436/622377Background: Primary hyperparathyroidism (PHPT), a disorder in which the parathyroid glands produce excessive amounts of parathyroid hormone, is most common in older adults and postmenopausal women. While most people with PHPT are asymptomatic at diagnosis, symptomatic disease can lead to hypercalcaemia, osteoporosis, renal stones, cardiovascular abnormalities and reduced quality of life. Surgical removal of abnormal parathyroid tissue (parathyroidectomy) is the only established treatment for adults with symptomatic PHPT to prevent exacerbation of symptoms and to be cured of PHPT. However, the benefits and risks of parathyroidectomy compared to simple observation or medical therapy for asymptomatic and mild PHPT are not well established. Objectives: To evaluate the benefits and harms of parathyroidectomy in adults with PHPT compared to simple observation or medical therapy. Search methods: We searched CENTRAL, MEDLINE, LILACS, ClinicalTrials.gov and WHO ICTRP from their date of inception until 26 November 2021. We applied no language restrictions. Selection criteria: We included randomised controlled trials (RCTs) comparing parathyroidectomy with simple observation or medical therapy for the treatment of adults with PHPT. Data collection and analysis: We used standard Cochrane methods. Our primary outcomes were 1. cure of PHPT, 2. morbidity related to PHPT and 3. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. health-related quality of life and 3. hospitalisation for hypercalcaemia, acute renal impairment or pancreatitis. We used GRADE to assess the certainty of the evidence for each outcome. Main results: We identified eight eligible RCTs that included 447 adults with (mostly asymptomatic) PHPT; 223 participants were randomised to parathyroidectomy. Follow-up duration varied from six months to 24 months. Of the 223 participants (37 men) randomised to surgery, 164 were included in the analyses, of whom 163 were cured at six to 24 months (overall cure rate 99%). Parathyroidectomy compared to observation probably results in a large increase in cure rate at six to 24 months follow-up: 163/164 participants (99.4%) in the parathyroidectomy group and 0/169 participants in the observation or medical therapy group were cured of their PHPT (8 studies, 333 participants; moderate certainty). No studies explicitly reported intervention effects on morbidities related to PHPT, such as osteoporosis, osteopenia, kidney dysfunction, urolithiasis, cognitive dysfunction or cardiovascular disease, although some studies reported surrogate outcomes for osteoporosis and cardiovascular disease. A post-hoc analysis revealed that parathyroidectomy, compared to observation or medical therapy, may have little or no effect after one to two years on bone mineral density (BMD) at the lumbar spine (mean difference (MD) 0.03 g/cm2,95% CI −0.05 to 0.12; 5 studies, 287 participants; very low certainty). Similarly, compared to observation, parathyroidectomy may have little or no effect on femoral neck BMD after one to two years (MD −0.01 g/cm2, 95% CI −0.13 to 0.11; 3 studies, 216 participants; very low certainty). However, the evidence is very uncertain for both BMD outcomes. Furthermore, the evidence is very uncertain about the effect of parathyroidectomy on improving left ventricular ejection fraction (MD −2.38%, 95% CI −4.77 to 0.01; 3 studies, 121 participants; very low certainty). Four studies reported serious adverse events. Three of these reported zero events in both the intervention and control groups; consequently, we were unable to include data from these three studies in the pooled analysis. The evidence suggests that parathyroidectomy compared to observation may have little or no effect on serious adverse events (RR 3.35, 95% CI 0.14 to 78.60; 4 studies, 168 participants; low certainty). Only two studies reported all-cause mortality. One study could not be included in the pooled analysis as zero events were observed in both the intervention and control groups. Parathyroidectomy compared to observation may have little or no effect on all-cause mortality, but the evidence is very uncertain (RR 2.11, 95% CI 0.20 to 22.60; 2 studies, 133 participants; very low certainty). Three studies measured health-related quality of life using the 36-Item Short Form Health Survey (SF-36) and reported inconsistent differences in scores for different domains of the questionnaire between parathyroidectomy and observation. Six studies reported hospitalisations for the correction of hypercalcaemia. Two studies reported zero events in both the intervention and control groups and could not be included in the pooled analysis. Parathyroidectomy, compared to observation, may have little or no effect on hospitalisation for hypercalcaemia (RR 0.91, 95% CI 0.20 to 4.25; 6 studies, 287 participants; low certainty). There were no reported hospitalisations for renal impairment or pancreatitis. Authors' conclusions: In accordance with the literature, our review findings suggest that parathyroidectomy, compared to simple observation or medical (etidronate) therapy, probably results in a large increase in cure rates of PHPT (with normalisation of serum calcium and parathyroid hormone levels to laboratory reference values). Parathyroidectomy, compared with observation, may have little or no effect on serious adverse events or hospitalisation for hypercalcaemia, and the evidence is very uncertain about the effect of parathyroidectomy on other short-term outcomes, such as BMD, all-cause mortality and quality of life. The high uncertainty of evidence limits the applicability of our findings to clinical practice; indeed, this systematic review provides no new insights with regard to treatment decisions for people with (asymptomatic) PHPT. In addition, the methodological limitations of the included studies, and the characteristics of the study populations (mainly comprising white women with asymptomatic PHPT), warrant caution when extrapolating the results to other populations with PHPT. Large-scale multi-national, multi-ethnic and long-term RCTs are needed to explore the potential short- and long-term benefits of parathyroidectomy compared to non-surgical treatment options with regard to osteoporosis or osteopenia, urolithiasis, hospitalisation for acute kidney injury, cardiovascular disease and quality of life.Published versio

A prediction algorithm to improve the accuracy of the Gold Standard Framework Surprise Question end-of-life prognostic categories in an acute hospital admission cohort-controlled study. The Proactive Risk-Based and Data-Driven Assessment of Patients at the End of Life (PRADA)

Objective To determine the accuracy of a clinical data algorithm allocated end-of-life prognosis amongst hospital inpatients.Method The model allocated a predicted Gold Standard Framework end-of-life prognosis to all acute medical patients admitted over a 2-year period. Mortality was determined at 1 year.Results Of 18,838 patients, end-of-life prognosis was unknown in 67.9%. A binary logistic regression model calculated 1-year mortality probability (X2=6650.2, p or < 1 year respectively), with subsidiary classification of “No” to Green (months), Amber (weeks) or Red (days). This digitally driven prognosis allocation (100% vs baseline 32.1%) yielded cohorts of GSFSQ-Yes 15,264 (81%), GSFSQ-No Green 1,771 (9.4%) and GSFSQ-No Amber or Red 1,803 (9.6%).There were 5,043 (26.8%) deaths at 1 year. In Cox’s survival, model allocated cohorts were discrete for mortality (GSFSQ-Yes 16.4% v GSFSQ-No 71.0% (p<0.001). For the GSFSQ-No classification, the mortality Odds Ratio was 12.4 (11.4 – 13.5) (p<0.001) vs GSFSQ-Yes (c-statistic of 0.71 (0.70 – 0.73), p<0.001; accuracy, positive and negative predictive values of 81.2%, 83.6%, 83.6% respectively. If this tool had been utilised at the time of admission, the potential to reduce subsequent hospital admissions, death-in-hospital, and bed days was all p<0.001.Conclusions The defined model successfully allocated end-of-life prognosis in cohorts of hospitalised patients with strong performance metrics for prospective 1 year mortality, yielding the potential to provide anticipatory care and improve outcomes

Digital health and inpatient palliative care: a cohort-controlled study

Objectives End of life has unacceptable levels of hospital admission and death. We aimed to determine the association of a novel digital specific system (Proactive Risk-Based and Data-Driven Assessment of Patients at the End of Life, PRADA) to modify such events.Methods A cohort-controlled study of those discharged alive, who died within 90 days of discharge, comparing PRADA (n=114) with standard care (n=3730).Results At 90 days, the PRADA group were more likely to die (78.9% vs 46.2%, p<0.001), had a shorter time to death (58±90 vs 178±186 days, p<0.001) but readmission (20.2% vs 37.9%, p<0.001) or death in hospital (4.4% vs 28.9%, p<0.001) was lower with reduced risk for a combined 90-day outcome of postdischarge non-elective admission or hospital death (OR 0.45, 95% CI 0.27–0.74, p<0.001). Tightening criteria with 1:1 matching (n=83 vs 83) showed persistent significant findings in PRADA contact with markedly reduced adverse events (OR 0.15, 95% CI 0.02–0.96, p<0.05).Conclusions Being seen in hospital by a specialist palliative care team using the PRADA tool was associated with significantly improved postdischarge outcomes pertaining to those destined to die after discharge