Impact of deprivation and comorbidity on outcomes in emergency general surgery: an epidemiological study.

BACKGROUND: The impact of socioeconomic deprivation and comorbidities on the outcome of patients who require emergency general surgery (EGS) admission is poorly understood. The aim of this study was to examine the effect of deprivation and comorbidity on mortality, discharge destination and length of hospital stay (LOS) in patients undergoing EGS in Scotland. METHODS: Prospectively collected data from all Scottish adult patients (aged >15 years) requiring EGS admitted between 1997 and 2016 were obtained from the Scottish Government. Data included age, sex, Scottish Index of Multiple Deprivation (SIMD), 5-year Charlson Comorbidity Index (CCI), whether an operation took place and outcomes including mortality, discharge destination and LOS. Logistic regression was used for the analysis of mortality and discharge destination and Poisson regression was used for LOS. RESULTS: 1 477 810 EGS admissions were analyzed. 16.2% were in the most deprived SIMD decile and 5.6% in the least deprived SIMD decile. 75.6% had no comorbidity, 20.3% had mild comorbidity, 2.5% had moderate comorbidity and 1.6% had severe comorbidity. 78.6% were discharged directly home. Inpatient, 30-day, 90-day and 1-year crude mortality was 1.7%, 3.7%, 7.2% and 12.4%, respectively. Logistic regression showed that severe comorbidity was associated with not being discharged directly to home (OR 0.38, 95% CI 0.37 to 0.39) and higher inpatient mortality (OR 13.74, 95% CI 13.09 to 14.42). Compared with the most affluent population, the most deprived population were less likely to be discharged directly to home (OR 0.97, 95% CI 0.95 to 0.99) and had higher inpatient mortality (OR 1.36, 95% CI 1.8 to 1.46). Poisson analysis showed that severe comorbidity (OR 1.69, 95% CI 1.68 to 1.69) and socioeconomic deprivation (OR 1.11, 95% CI 1.11 to 1.12) were associated with longer LOS. DISCUSSION: Increased levels of comorbidity and, to a lesser extent, socioeconomic deprivation are key drivers of mortality, discharge destination and LOS following admission to an EGS service. LEVEL OF EVIDENCE: III (prospective/retrospective with up to two negative criteria). STUDY TYPE: Epidemiological/prognostic

Emergency general surgery: impact of distance and rurality on mortality

Funding This work was made possible by a grant from NHS Grampian and NHS Highlands Endowment Funding. No funding was received from the National Institutes of Health (NIH); Wellcome Trust; or Howard Hughes Medical Institute (HHMI). Acknowledgements The authors acknowledge the support of the eDRIS Team (Public Health Scotland) for their involvement in obtaining approvals, provisioning, and linking data, and the use of the secure analytical platform within the National Safe Haven. We also acknowledge P. Murchie for support with contextualizing the work within the rural medical practitioner literature.Peer reviewedPublisher PD

The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study

Introduction: A limitation of pre-hospital monitoring is that vital signs often do not change until a patient is in a critical stage. Blood lactate levels are suggested as a more sensitive parameter to evaluate a patient's condition. The aim of this pilot study was to find presumptive evidence for a relation between pre-hospital lactate levels and in-hospital mortality, corrected for vital sign abnormalities. Methods: In this prospective observational study (n = 124), patients who required urgent ambulance dispatching and had a systolic blood pressure below 100 mmHg, a respiratory rate less than 10 or more than 29 breaths/ minute, or a Glasgow Coma Scale (GCS) below 14 were enrolled. Nurses from Emergency Medical Services measured capillary or venous lactate levels using a hand-held device on arrival at the scene (T1) and just before or on arrival at the emergency department (T2). The primary outcome measured was in-hospital mortality. Results: The average (standard deviation) time from T1 to T2 was 27 (10) minutes. Non-survivors (n = 32, 26%) had significantly higher lactate levels than survivors at T1 (5.3 vs 3.7 mmol/L) and at T2 (5.4 vs 3.2 mmol/L). Mortality was significantly higher in patients with lactate levels of 3.5 mmol/L or higher compared with those with lactate levels below 3.5 mmol/L (T1: 41 vs 12% and T2: 47 vs 15%). Also in the absence of hypotension, mortality was higher in those with higher lactate levels. In a multivariable Cox proportional hazard analysis including systolic blood pressure, heart rate, GCS (all at T1) and delta lactate level (from T1 to T2), only delta lactate level (hazard ratio (HR) = 0.20, 95% confidence interval (CI) = 0.05 to 0.76, p = 0.018) and GCS (HR = 0.93, 95% CI = 0.88 to 0.99, p = 0.022) were significant independent predictors of in-hospital mortality. Conclusions: In a cohort of patients that required urgent ambulance dispatching, pre-hospital blood lactate levels were associated with in-hospital mortality and provided prognostic information superior to that provided by the patient's vital signs. There is potential for early detection of occult shock and pre-hospital resuscitation guided by lactate measurement. However, external validation is required before widespread implementation of lactate measurement in the out-of-hospital setting

The tumor suppressor Scrib interacts with the zyxin-related protein LPP, which shuttles between cell adhesion sites and the nucleus

BACKGROUND: At sites of cell adhesion, proteins exist that not only perform structural tasks but also have a signaling function. Previously, we found that the Lipoma Preferred Partner (LPP) protein is localized at sites of cell adhesion such as focal adhesions and cell-cell contacts, and shuttles to the nucleus where it has transcriptional activation capacity. LPP is a member of the zyxin family of proteins, which contains five members: ajuba, LIMD1, LPP, TRIP6 and zyxin. LPP has three LIM domains (zinc-finger protein interaction domains) at its carboxy-terminus, which are preceded by a proline-rich pre-LIM region containing a number of protein interaction domains. RESULTS: To catch the role of LPP at sites of cell adhesion, we made an effort to identify binding partners of LPP. We found the tumor suppressor protein Scrib, which is a component of cell-cell contacts, as interaction partner of LPP. Human Scrib, which is a functional homologue of Drosophila scribble, is a member of the leucine-rich repeat and PDZ (LAP) family of proteins that is involved in the regulation of cell adhesion, cell shape and polarity. In addition, Scrib displays tumor suppressor activity. The binding between Scrib and LPP is mediated by the PDZ domains of Scrib and the carboxy-terminus of LPP. Both proteins localize in cell-cell contacts. Whereas LPP is also localized in focal adhesions and in the nucleus, Scrib could not be detected at these locations in MDCKII and CV-1 cells. Furthermore, our investigations indicate that Scrib is dispensable for targeting LPP to focal adhesions and to cell-cell contacts, and that LPP is not necessary for localizing Scrib in cell-cell contacts. We show that all four PDZ domains of Scrib are dispensable for localizing this protein in cell-cell contacts. CONCLUSIONS: Here, we identified an interaction between one of zyxin's family members, LPP, and the tumor suppressor protein Scrib. Both proteins localize in cell-cell contacts. This interaction links Scrib to a communication pathway between cell-cell contacts and the nucleus, and implicates LPP in Scrib-associated functions

Primordial magnetic fields at preheating

Using lattice techniques we investigate the generation of long range cosmological magnetic fields during a cold electroweak transition. We will show how magnetic fields arise, during bubble collisions, in the form of magnetic strings. We conjecture that these magnetic strings originate from the alignment of magnetic dipoles associated with EW sphaleron-like configurations. We also discuss the early thermalisation of photons and the turbulent behaviour of the scalar fields after tachyonic preheating.Comment: 7 pages. Talk presented at Lattice200

Whole home exercise intervention for depression in older care home residents (the OPERA study) : a process evaluation

Background: The ‘Older People’s Exercise intervention in Residential and nursing Accommodation’ (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect. Methods: The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known. Results: Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises. Conclusions: The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms

The Light Stop Scenario from Gauge Mediation

In this paper we embed the light stop scenario, a MSSM framework which explains the baryon asymmetry of the universe through a strong first order electroweak phase transition, in a top-down approach. The required low energy spectrum consists in the light SM-like Higgs, the right-handed stop, the gauginos and the Higgsinos while the remaining scalars are heavy. This spectrum is naturally driven by renormalization group evolution starting from a heavy scalar spectrum at high energies. The latter is obtained through a supersymmetry-breaking mix of gauge mediation, which provides the scalars masses by new gauge interactions, and gravity mediation, which generates gaugino and Higgsino masses. This supersymmetry breaking also explains the \mu\ and B_\mu\ parameters necessary for electroweak breaking and predicts small tri-linear mixing terms A_t in agreement with electroweak baryogenesis requirements. The minimal embedding predicts a Higgs mass around its experimental lower bound and by a small extension higher masses m_H\lesssim 127 GeV can be accommodated.Comment: 20 pages, 3 figures; v2: changes in the conventions; v3: more details on the Higgs mass prediction, version published in JHE

Post-streptococcal reactive arthritis in children: a distinct entity from acute rheumatic fever

There is a debate whether post-streptococcal reactive arthritis (PSRA) is a separate entity or a condition on the spectrum of acute rheumatic fever (ARF). We believe that PSRA is a distinct entity and in this paper we review the substantial differences between PSRA and ARF. We show how the demographic, clinical, genetic and treatment characteristics of PSRA differ from ARF. We review diagnostic criteria and regression formulas that attempt to classify patients with PSRA as opposed to ARF. The important implication of these findings may relate to the issue of prophylactic antibiotics after PSRA. However, future trials will be necessary to conclusively answer that question

A method for the allocation of sequencing resources in genotyped livestock populations

International audienceAbstractBackgroundThis paper describes a method, called AlphaSeqOpt, for the allocation of sequencing resources in livestock populations with existing phased genomic data to maximise the ability to phase and impute sequenced haplotypes into the whole population.MethodsWe present two algorithms. The first selects focal individuals that collectively represent the maximum possible portion of the haplotype diversity in the population. The second allocates a fixed sequencing budget among the families of focal individuals to enable phasing of their haplotypes at the sequence level. We tested the performance of the two algorithms in simulated pedigrees. For each pedigree, we evaluated the proportion of population haplotypes that are carried by the focal individuals and compared our results to a variant of the widely-used key ancestors approach and to two haplotype-based approaches. We calculated the expected phasing accuracy of the haplotypes of a focal individual at the sequence level given the proportion of the fixed sequencing budget allocated to its family.ResultsAlphaSeqOpt maximises the ability to capture and phase the most frequent haplotypes in a population in three ways. First, it selects focal individuals that collectively represent a larger portion of the population haplotype diversity than existing methods. Second, it selects focal individuals from across the pedigree whose haplotypes can be easily phased using family-based phasing and imputation algorithms, thus maximises the ability to impute sequence into the rest of the population. Third, it allocates more of the fixed sequencing budget to focal individuals whose haplotypes are more frequent in the population than to focal individuals whose haplotypes are less frequent. Unlike existing methods, we additionally present an algorithm to allocate part of the sequencing budget to the families (i.e. immediate ancestors) of focal individuals to ensure that their haplotypes can be phased at the sequence level, which is essential for enabling and maximising subsequent sequence imputation.ConclusionsWe present a new method for the allocation of a fixed sequencing budget to focal individuals and their families such that the final sequenced haplotypes, when phased at the sequence level, represent the maximum possible portion of the haplotype diversity in the population that can be sequenced and phased at that budget