Annual risk of falls resulting in emergency department and hospital attendances for older people: an observational study of 781,081 individuals living in Wales (United Kingdom) including deprivation, frailty and dementia diagnoses between 2010 and 2020

Backgroundfalls are common in older people, but associations between falls, dementia and frailty are relatively unknown. The impact of the COVID-19 pandemic on falls admissions has not been studied.Aimto investigate the impact of dementia, frailty, deprivation, previous falls and the differences between years for falls resulting in an emergency department (ED) or hospital admission.Study Designlongitudinal cross-sectional observational study.Settingolder people (aged 65+) resident in Wales between 1 January 2010 and 31 December 2020.Methodswe created a binary (yes/no) indicator for a fall resulting in an attendance to an ED, hospital or both, per person, per year. We analysed the outcomes using multilevel logistic and multinomial models.Resultswe analysed a total of 5,141,244 person years of data from 781,081 individuals. Fall admission rates were highest in 2012 (4.27%) and lowest in 2020 (4.27%). We found an increased odds ratio (OR [95% confidence interval]) of a fall admission for age (1.05 [1.05, 1.05] per year of age), people with dementia (2.03 [2.00, 2.06]) and people who had a previous fall (2.55 [2.51, 2.60]). Compared with fit individuals, those with frailty had ORs of 1.60 [1.58, 1.62], 2.24 [2.21, 2.28] and 2.94 [2.89, 3.00] for mild, moderate and severe frailty respectively. Reduced odds were observed for males (0.73 [0.73, 0.74]) and less deprived areas; most deprived compared with least OR 0.75 [0.74, 0.76].Conclusionsfalls prevention should be targeted to those at highest risk, and investigations into the reduction in admissions in 2020 is warranted

The impact of dementia, frailty and care home characteristics on SARS-CoV-2 incidence in a national cohort of Welsh care home residents during a period of high community prevalence

Backgrounddementia may increase care home residents’ risk of COVID-19, but there is a lack of evidence on this effect and on interactions with individual and care home-level factors.Methodswe created a national cross-sectional retrospective cohort of care home residents in Wales for 1 September to 31 December 2020. Risk factors were analysed using multi-level logistic regression to model the likelihood of SARS-CoV-2 infection and mortality.Resultsthe cohort included 9,571 individuals in 673 homes. Dementia was diagnosed in 5,647 individuals (59%); 1,488 (15.5%) individuals tested positive for SARS-CoV-2. We estimated the effects of age, dementia, frailty, care home size, proportion of residents with dementia, nursing and dementia services, communal space and region. The final model included the proportion of residents with dementia (OR for positive test 4.54 (95% CIs 1.55–13.27) where 75% of residents had dementia compared to no residents with dementia) and frailty (OR 1.29 (95% CIs 1.05–1.59) for severe frailty compared with no frailty). Analysis suggested 76% of the variation was due to setting rather than individual factors. Additional analysis suggested severe frailty and proportion of residents with dementia was associated with all-cause mortality, as was dementia diagnosis. Mortality analyses were challenging to interpret.Discussionwhilst individual frailty increased the risk of COVID-19 infection, dementia was a risk factor at care home but not individual level. These findings suggest whole-setting interventions, particularly in homes with high proportions of residents with dementia and including those with low/no individual risk factors may reduce the impact of COVID-19

COVID-19 Infection Risk amongst 14,104 Vaccinated Care Home Residents: A national observational longitudinal cohort study in Wales, United Kingdom, December 2020 to March 2021

Backgroundvaccinations for COVID-19 have been prioritised for older people living in care homes. However, vaccination trials included limited numbers of older people.Aimwe aimed to study infection rates of SARS-CoV-2 for older care home residents following vaccination and identify factors associated with increased risk of infection.Study Design and Settingwe conducted an observational data-linkage study including 14,104 vaccinated older care home residents in Wales (UK) using anonymised electronic health records and administrative data.Methodswe used Cox proportional hazards models to estimate hazard ratios (HRs) for the risk of testing positive for SARS-CoV-2 infection following vaccination, after landmark times of either 7 or 21 days post-vaccination. We adjusted HRs for age, sex, frailty, prior SARS-CoV-2 infections and vaccination type.Resultswe observed a small proportion of care home residents with positive polymerase chain reaction (tests following vaccination 1.05% (N = 148), with 90% of infections occurring within 28 days. For the 7-day landmark analysis we found a reduced risk of SARS-CoV-2 infection for vaccinated individuals who had a previous infection; HR (95% confidence interval) 0.54 (0.30, 0.95). For the 21-day landmark analysis, we observed high HRs for individuals with low and intermediate frailty compared with those without; 4.59 (1.23, 17.12) and 4.85 (1.68, 14.04), respectively.Conclusionsincreased risk of infection after 21 days was associated with frailty. We found most infections occurred within 28 days of vaccination, suggesting extra precautions to reduce transmission risk should be taken in this time frame

Intensity of COVID-19 in care homes following Hospital Discharge in the early stages of the UK epidemic

BackgroundA defining feature of the COVID-19 pandemic in many countries was the tragic extent to which care home residents were affected, and the difficulty preventing introduction and subsequent spread of infection. Management of risk in care homes requires good evidence on the most important transmission pathways. One hypothesised route at the start of the pandemic, prior to widespread testing, was transfer of patients from hospitals, which were experiencing high levels of nosocomial events.MethodsWe tested the hypothesis that hospital discharge events increased the intensity of care home cases using a national individually linked health record cohort in Wales, UK. We monitored 186,772 hospital discharge events over the period March to July 2020, tracking individuals to 923 care homes and recording the daily case rate in the homes populated by 15,772 residents. We estimated the risk of an increase in cases rates following exposure to a hospital discharge using multi-level hierarchical logistic regression, and a novel stochastic Hawkes process outbreak model.FindingsIn regression analysis, after adjusting for care home size, we found no significant association between hospital discharge and subsequent increases in care home case numbers (odds ratio: 0.99, 95% CI 0.82, 1.90). Risk factors for increased cases included care home size, care home resident density, and provision of nursing care. Using our outbreak model, we found a significant effect of hospital discharge on the subsequent intensity of cases. However, the effect was small, and considerably less than the effect of care home size, suggesting the highest risk of introduction came from interaction with the community. We estimated approximately 1.8% of hospital discharged patients may have been infected.InterpretationThere is growing evidence in the UK that the risk of transfer of COVID-19 from the high-risk hospital setting to the high-risk care home setting during the early stages of the pandemic was relatively small. Although access to testing was limited to initial symptomatic cases in each care home at this time, our results suggest that reduced numbers of discharges, selection of patients, and action taken within care homes following transfer all may have contributed to mitigation. The precise key transmission routes from the community remain to be quantified

Mitotic phosphorylation by NEK6 and NEK7 reduces the microtubule affinity of EML4 to promote chromosome congression

EML4 is a microtubule-associated protein that promotes microtubule stability. We investigated its regulation across the cell cycle and found that EML4 was distributed as punctate foci along the microtubule lattice in interphase but exhibited reduced association with spindle microtubules in mitosis. Microtubule sedimentation and cryo–electron microscopy with 3D reconstruction revealed that the basic N-terminal domain of EML4 mediated its binding to the acidic C-terminal tails of α- and β-tubulin on the microtubule surface. The mitotic kinases NEK6 and NEK7 phosphorylated the EML4 N-terminal domain at Ser144 and Ser146 in vitro, and depletion of these kinases in cells led to increased EML4 binding to microtubules in mitosis. An S144A-S146A double mutant not only bound inappropriately to mitotic microtubules but also increased their stability and interfered with chromosome congression. In addition, constitutive activation of NEK6 or NEK7 reduced the association of EML4 with interphase microtubules. Together, these data support a model in which NEK6- and NEK7-dependent phosphorylation promotes the dissociation of EML4 from microtubules in mitosis in a manner that is required for efficient chromosome congression

Variation in Type and Frequency of Diagnostic Imaging During Trauma Care Across Multiple Time Points by Patient Insurance Type

BACKGROUND: Research has shown that uninsured patients receive fewer radiographic studies during trauma care, but less is known as to whether differences in care are present among other insurance groups or across different time points during hospitalization. Our objective was to examine the number of radiographic studies administered to a cohort of trauma patients over the entire hospital stay as well as during the first 24-hours of care. METHODS: Patient data were obtained from an American College of Surgeons (ACS) verified Level I Trauma Center between January 1, 2011 and December 31, 2012. We used negative binomial regression to construct relative risk (RR) ratios for type and frequency of radiographic imaging received among persons with Medicare, Medicaid, no insurance, or government insurance plans in reference to those with commercial indemnity plans. The analysis was adjusted for patient age, sex, race/ethnicity, injury severity score, injury mechanism, comorbidities, complications, hospital length of stay, and Intensive Care Unit (ICU) admission. RESULTS: A total of 3621 records from surviving patients age \u3e =18 years were assessed. After adjustment for potential confounders, the expected number of radiographic studies decreased by 15 % among Medicare recipients (RR 0.85, 95 % CI 0.78-0.93), 11 % among Medicaid recipients (0.89, 0.81-0.99), 10 % among the uninsured (0.90, 0.85-0.96) and 19 % among government insurance groups (0.81, 0.72-0.90), compared with the reference group. This disparity was observed during the first 24-hours of care among patients with Medicare (0.78, 0.71-0.86) and government insurance plans (0.83, 0.74-0.94). Overall, there were no differences in the number of radiographic studies among the uninsured or among Medicaid patients during the first 24-hours of care compared with the reference group, but differences were observed among the uninsured in a sub-analysis of severely injured patients (ISS \u3e 15). CONCLUSIONS: Both uninsured and insured patients treated at a not-for-profit verified Level I Trauma Center receive fewer radiographic studies than patients with commercial indemnity plans, even after adjusting for clinical and demographic confounders. There is less disparity in care during the first 24-hours, which suggests that patient pathology is the determining factor for radiographic evaluation during the acute care phase. Results from this study offer initial evidence of disparity in diagnostic imaging across multiple insurance groups over different periods of trauma care

Staff-Pupil SARS-CoV-2 Infection Pathways in Schools: A Population Level Linked Data Approach

Background Better understanding of the role that children and school staff play in the transmission of SARS-CoV-2 is essential to guide policy development on controlling infection while minimising disruption to children’s education and well-being.Methods Our national e-cohort (n=464531) study used anonymised linked data for pupils, staff and associated households linked via educational settings in Wales. We estimated the odds of testing positive for SARS-CoV-2 infection for staff and pupils over the period August– December 2020, dependent on measures of recent exposure to known cases linked to their educational settings.Results The total number of cases in a school was not associated with a subsequent increase in the odds of testing positive (staff OR per case: 0.92, 95% CI 0.85 to 1.00; pupil OR per case: 0.98, 95% CI 0.93 to 1.02). Among pupils, the number of recent cases within the same year group was significantly associated with subsequent increased odds of testing positive (OR per case: 1.12, 95% CI 1.08 to 1.15). These effects were adjusted for a range of demographic covariates, and in particular any known cases within the same household, which had the strongest association with testing positive (staff OR: 39.86, 95% CI 35.01 to 45.38; pupil OR: 9.39, 95% CI 8.94 to 9.88).Conclusions In a national school cohort, the odds of staff testing positive for SARS-CoV-2 infection were not significantly increased in the 14-day period after case detection in the school. However, pupils were found to be at increased odds, following cases appearing within their own year group, where most of their contacts occur. Strong mitigation measures over the whole of the study period may have reduced wider spread within the school environment

Assessment of the Thermal Behaviour of Rammed Earth Walls in the Summer Period

[EN] The constructive solutions characteristic of vernacular architecture are the result of the convergence of geographical, cultural and climatic factors that bring about constructions characterised by adaptation to their surroundings. However, at present, Spanish regulations do not contemplate the properties of traditional materials, such as those found in earthen constructions, whose great thermal inertia is ignored despite their thermal gains and compensations. Given these limitations, the purpose of this study is to assess the thermal behaviour of traditional earthen architecture adjusting to its real performance and original surroundings. This work thus examines a methodology to assess the thermal behaviour of rammed earth walls based on on-site data specifically collected in the summer in a case study located in La Serrania, a region in the northwest of the province of Valencia (Spain). The results show the evolution of exterior and interior surface temperatures of the earthen wall, quantifying its variation frequency and thermal energy transmission. Based on these data, the thermal transmittance of the wall is calculated and compared to highlight the difference from the normalised value, showing that a review of the Spanish regulations applied to earthen architecture is needed.This research was funded by the Spanish Ministry of Economy and Competitiveness as the work was part of the research project "Restoration and rehabilitation of traditional earthen architecture in the Iberian Peninsula. Guidelines and tools for a sustainable intervention" (Ref.: BIA2014-55924-R; main researchers: Camilla Mileto and Fernando Vegas Lopez-Manzanares)Balaguer-Garzón, L.; Vegas López-Manzanares, F.; Mileto, C.; García-Soriano, L. (2019). Assessment of the Thermal Behaviour of Rammed Earth Walls in the Summer Period. Sustainability. 11(7):1-12. https://doi.org/10.3390/su11071924S112117Código Técnico de la Edificación https://www.codigotecnico.orgMartínez-Molina, A., Tort-Ausina, I., Cho, S., & Vivancos, J.-L. (2016). Energy efficiency and thermal comfort in historic buildings: A review. Renewable and Sustainable Energy Reviews, 61, 70-85. doi:10.1016/j.rser.2016.03.018Webb, A. L. (2017). Energy retrofits in historic and traditional buildings: A review of problems and methods. Renewable and Sustainable Energy Reviews, 77, 748-759. doi:10.1016/j.rser.2017.01.145De Fino, M., Scioti, A., Cantatore, E., & Fatiguso, F. (2017). Methodological framework for assessment of energy behavior of historic towns in Mediterranean climate. Energy and Buildings, 144, 87-103. doi:10.1016/j.enbuild.2017.03.029Heathcote, K. (2011). El comportamiento térmico de los edificios de tierra. Informes de la Construcción, 63(523), 117-126. doi:10.3989/ic.10.024Balaguer, L., Mileto, C., Vegas López-Manzanares, F., & García-Soriano, L. (2019). Bioclimatic strategies of traditional earthen architecture. Journal of Cultural Heritage Management and Sustainable Development, 9(2), 227-246. doi:10.1108/jchmsd-07-2018-005