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COVID-19 has caused a major global pandemic and necessitated unprecedented public health restrictions in almost every country. Understanding risk factors for severe disease in hospitalised patients is critical as the pandemic progresses. This observational cohort study aimed to characterise the independent associations between the clinical outcomes of hospitalised patients and their demographics, comorbidities, blood tests and bedside observations. All patients admitted to Northwick Park Hospital, London, UK between 12 March and 15 April 2020 with COVID-19 were retrospectively identified. The primary outcome was death. Associations were explored using Cox proportional hazards modelling. The study included 981 patients. The mortality rate was 36.0%. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Scale <15 (aHR 1.92), urea (aHR 2.67), alkaline phosphatase (aHR 2.53), C-reactive protein (aHR 1.15), lactate (aHR 2.67), platelet count (aHR 0.77) and infiltrates on chest radiograph (aHR 1.89) were all associated with mortality. These important data will aid clinical risk stratification and provide direction for further research.
Evaluation of post-operative donor site disability remains unaddressed in radial forearm free flap cases. This study aimed to assess donor site dysfunction following radial forearm free flap harvest using validated general, disease-specific and site-specific disability questionnaires.
In this retrospective case series of 24 patients at a tertiary academic medical centre, patients were assessed using the Short Form 36 Health Survey, Short Musculoskeletal Function Assessment questionnaire, and Disabilities of the Arm, Shoulder and Hand questionnaire. One-sample z-tests were performed, comparing means of the cohort to controls.
Compared to population controls, the cohort had higher mean scores for the Disabilities of the Arm, Shoulder and Hand questionnaire (18.22 vs 10.1, p < 0.01), and Short Musculoskeletal Function Assessment questionnaire bothersome index (21.44 vs 13.77, p = 0.04), and a lower mean score for the Short Form 36 Health Survey physical component (38.88 vs 50, p < 0.01), indicating a greater disability for the cohort compared to controls.
Radial forearm free flap harvest causes significant long-term donor site disability in head and neck tumour patients. The Disabilities of the Arm, Shoulder and Hand questionnaire is a concise tool for measuring this dysfunction.
The aim of this study was to describe patient level costing methods and develop a database of healthcare resource use and cost in patients with AHF receiving ventricular assist device (VAD) therapy.
Patient level micro-costing was used to identify documented activity in the years preceding and following VAD implantation, and preceding heart transplant for a cohort of seventy-seven consecutive patients listed for heart transplantation (2009–12). Clinician interviews verified activity, established time resource required for each activity, and added additional undocumented activities. Costs were sourced from the general ledger, salary, stock price, pharmacy formulary data, and from national medical benefits and prostheses lists. Linked administrative data analyses of activity external to the implanting institution, used National Weighted Activity Units (NWAU), 2014 efficient price, and admission complexity cost weights and were compared with micro-costed data for the implanting admission.
The database produced includes patient level activity and costs associated with the seventy-seven patients across thirteen resource areas including hospital activity external to the implanting center. The median cost of the implanting admission using linked administrative data was $246,839 (interquartile range [IQR] $246,839–$271,743), versus $270,716 (IQR $211,740–$378,482) for the institutional micro-costing (p = .08).
Linked administrative data provides a useful alternative for imputing costs external to the implanting center, and combined with institutional data can illuminate both the pathways to transplant referral and the hospital activity generated by patients experiencing the terminal phases of heart failure in the year before transplant, cf-VAD implant, or death.
Palliative care for nursing home residents with advanced dementia is often sub-optimal due to poor communication and limited care planning. In a cluster randomized controlled trial, registered nurses (RNs) from 10 nursing homes were trained and funded to work as Palliative Care Planning Coordinators (PCPCs) to organize family case conferences and mentor staff. This qualitative sub-study aimed to explore PCPC and health professional perceptions of the benefits of facilitated case conferencing and identify factors influencing implementation.
Semi-structured interviews were conducted with the RNs in the PCPC role, other members of nursing home staff, and physicians who participated in case conferences. Analysis was conducted by two researchers using a thematic framework approach.
Interviews were conducted with 11 PCPCs, 18 other nurses, eight allied health workers, and three physicians. Perceived benefits of facilitated case conferencing included better communication between staff and families, greater multi-disciplinary involvement in case conferences and care planning, and improved staff attitudes and capabilities for dementia palliative care. Key factors influencing implementation included: staffing levels and time; support from management, staff and physicians; and positive family feedback.
The facilitated approach explored in this study addressed known barriers to case conferencing. However, current business models in the sector make it difficult for case conferencing to receive the required levels of nursing qualification, training, and time. A collaborative nursing home culture and ongoing relationships with health professionals are also prerequisites for success. Further studies should document resident and family perceptions to harness consumer advocacy.
Objectives: The aim of this study is to evaluate the cost-effectiveness of a patient-direct mailed advance notification letter on participants of a National Bowel Cancer Screening Program (NBCSP) in Australia, which was launched in August 2006 and offers free fecal occult blood testing to all Australians turning 50, 55, or 65 years of age in any given year.
Methods: This study followed a hypothetical cohort of 50-year-old, 55-year-old, and 65-year-old patients undergoing fecal occult blood test (FOBT) screening through a decision analytic Markov model. The intervention compared two strategies: (i) advance letter, NBCSP, and FOBT compared with (ii) NBCSP and FOBT. The main outcome measures were life-years gained (LYG), quality-adjusted life-years (QALYs) gained and incremental cost-effectiveness ratio.
Results: An advance notification screening letter would yield an additional 54 per 100,000 colorectal cancer deaths avoided compared with no letter. The estimated cost-effectiveness was $3,976 per LYG and $6,976 per QALY gained.
Conclusions: An advance notification letter in the NBCSP may have a significant impact on LYG and cancer deaths avoided. It is cost-effective and offers a feasible strategy that could be rolled out across other screening program at an acceptable cost.
The creation of the Scottish Parliament under the Scotland Act 1998 was without doubt a momentous political, constitutional and social happening in Scotland. The zeitgeist was captured at the first meeting of the Parliament in May 1999 by Dr Winnie Ewing, its most senior member, when she declared that “The Scottish Parliament, which adjourned on 25 March 1707, is hereby reconvened”. Although the constitutional actuality of the new Scottish Parliament, which exercises law-making competence subject to the statutory authority of the UK Parliament, is very different from that of the Scottish Parliament of 1707, which was the legislature of an independent nation state, the spring of 1999 was undoubtedly the beginning of a new political and constitutional era for the people of Scotland.
The objective of this collection of essays is to offer critical analysis of the first ten years of law making by the Scottish Parliament in a number of key areas, putting it into its wider policy and socio-legal context. As is inevitably the case in a collection of essays, individual topics are addressed on a subject-by-subject basis and, while a certain amount of the content is necessarily narrative in nature, the bulk of the content is critical and analytical. Each chapter is written by a leading expert in his or her field. Contributors were invited to subject the key legislative themes in their own areas to rigorous critical analysis and also, in this context, to consider whether the Parliament has achieved what had been hoped for when it was established by the Scotland Act.
As the tenth anniversary of the new Scottish Parliament approached, we believed the time was ripe to offer some assessment of the Parliament's contribution to various areas of Scots law. This volume is the result.
Of course, it is never as simple as that. First, there was the matter of selecting contributors for the individual chapters. Approaches were made to the bravest and the best from the wealth of talent found amongst Scotland's legal academics and practitioners: each was asked to pass judgment on the progress made by legislators, offering critical analysis of the Parliament's contribution in his or her field of expertise.
We would like to offer our profound thanks to the contributors who made time in their busy schedules to rise to the challenge, strove to meet our editorial guidelines and to do so timeously.
We were most gratified when the project was greeted with enthusiasm by the Edinburgh Legal Education Trust and we are indebted to the trustees and to Elspeth Reid for her insight and unfailing courtesy and efficiency in helping to steer us through the Trust's approval process in order that the volume could appear in the Edinburgh Studies in Law Series. Thereafter, the proposal was considered and accepted by Edinburgh University Press and we are grateful to Sarah Edwards, Eddie Clark and their colleagues for their assistance with editing and production.
Contributors have endeavoured to state the law as at 31 December 2009 and, on occasion, it has been possible to incorporate more recent developments.
To test whether the presence of indolyl-3-acryloylglycine (IAG) is associated with autism, we analyzed urine from population-based, blinded cohorts. All children in York, UK with autism spectrum disorders (ASDs), diagnosed using ICD-10 research diagnostic criteria, were invited to participate. Fifty-six children on the autism spectrum (mean age 9y 8mo, SD3y 8mo; 79% male) agreed to participate, as did 155 children without ASDs (mean age 10y, SD3y 2mo; 54% male) in mainstream and special schools (56 of whom were age-, sex-, and school-matched to children with ASDs). IAG was found at similar levels in the urine of all children, whether IAG concentrations or IAG:creatinine ratios were compared. There was no significant difference between the ASD and the comparison group, and no difference between children at mainstream schools and those at special schools. There is no association between presence of IAG in urine and autism; therefore, it is unlikely to be of help either diagnostically or as a basis for recommending therapeutic intervention with dietary manipulation. The significance of the presence of IAG in urine has yet to be determined.
In late 1996 a heraldic parcel-gilt badge (fig 1) was found during a metal detecting rally by Mr Martin Hay of Horley, Surrey, in a field just to the north of Chelsham Court Farm, near Chelsham, Surrey (National Grid Ref: TQ 388 586). The badge was subsequently brought by Mr David Williams of Reigate, Surrey, to the Department of Medieval and Later Antiquities at the British Museum for identification. It was established that the find had been made on land belonging to Earl Compton of Castle Ashby, Northamptonshire. The Chelsham estate was acquired by the Sixth Marquess of Northampton in 1943 and passed on via family Trustees to The Earl Compton in 1994. As this single find was made before the Treasure Act came into force on 24 September 1997, it does not qualify as Treasure under the terms of the new legislation. As a casual loss under the old regulations of Treasure Trove, ownership of the object was claimed by the landowner who has generously agreed to lend it to the British Museum for display purposes.
Scientific instruments carried aboard spacecraft often have to be equipped with mechanisms to operate shutters, protective covers, filter wheels, aperture changers and devices that focus, scan and calibrate, just as spacecraft themselves may have to be equipped with mechanisms such as deployable booms, reaction wheels and gas valves for manœuvrability, and driven shafts to steer antennae and solar arrays. This chapter focusses on the design principles of the former, treating them as a special branch of mechanical engineering, although somewhat paradoxically the system designer's first duty is to avoid the use of mechanisms wherever possible to reduce complexity and the risk of end–of–life failure.
We define a mechanism as a ‘system of mutually adapted parts working together’. It may provide useful relative movement, as for a focussing device in a photographic instrument. In the absence of a human operator, it may include a drive motor to overcome friction, or perhaps to perform controlled amounts of useful work. For example, the instrument might be a rock sample drill on a planetary lander. High powered machines such as rocket–engine turbopumps are not considered. The development of robotics (Yoshikawa, ) for manufacturing industry has been widespread in an era in which the remotely directed manipulator arm has been useful in space.
The electronics are usually digital, and have been largely dealt with in Chapter 4 already. (In a functioning space mechanism they can be so well integrated that the combined system is described by some authors as ‘mechatronics’.)
For spacecraft and their instruments, the engineering disciplines of mechanical and structural design work together, and both are founded on the study of the mechanics of materials. We create designs, then prove (by calculation and test) that they will work in the environments of rocket launch and flight. Mechanisms, by definition having relatively–moving parts, are not the whole of mechanical design; they are interesting enough to get a later chapter of this book (Chapter 5) to themselves. But any mechanism is itself a structure of some kind, since it sustains loads. We therefore define structures, which are more general than mechanisms, as ‘assemblies of materials which sustain loads’. All structures, whether blocks, boxes, beams, shells, frames or trusses of struts are thereby included.
Mechanical design should begin by considering the forces which load the structural parts. The twin objectives are to create a structure which is (i) strong enough not to collapse or break, and (ii) stiffly resistant against deforming too far. The importance of stiffness as a design goal will recur in this chapter. Forces may be static, or dynamic; if dynamic, changing slowly (quasi–static) or rapidly, as when due to vibration and shock. The dynamic forces are dominant in rocket flight, and vibrations are a harsh aspect both of the launch environment and of environmental testing, generating often large dynamic forces. To analyse each mechanical assembly as a structure, we shall need the concept of inertia force to represent the reaction to dynamic acceleration.
The dawn of the space age in 1957 was as historic in world terms as the discovery of the Americas, the voyage of the Beagle or the first flight by the Wright brothers. Indeed, the space age contains elements of each of these events. It is an age of exploration of new places, an opportunity to acquire new knowledge and ideas and the start of a technological revolution whose future benefits can only be guessed at. For these reasons, and others, space travel has captured the public's imagination.
Unfortunately, access to the space environment is not cheap either in terms of money or in fractions of the working life of an engineer or scientist. The design of space instruments should therefore only be undertaken if the scientific or engineering need cannot be met by other means, or, as sometimes happens, if instruments in space are actually the cheapest way to proceed, despite their cost. Designing instruments, or spacecraft for that matter, to work in the space environment places exacting requirements on those involved. Three issues arise in this kind of activity which add to the difficulty, challenge and excitement of carrying out science and engineering in space. First, it is by no means straightforward to design highly sophisticated instruments to work in the very hostile physical environment experienced in orbit. Secondly, since the instruments will work remotely from the design team, the processes of design, build, test, calibrate, launch and operate, must have an extremely high probability of producing the performance required for the mission to be regarded as a success.
At the end of the nineteen sixties satellites characteristically had masses in the range 150 to 300 kg. By the end of the nineteen nineties many, if not most, satellites are being designed to mass budgets between one and ten metric tonnes. Satellites have expanded to fill the launchers available would be one conclusion. In fact, many changes have taken place during the past thirty years and most of these have led to a growth in satellite masses. The scientific problems being solved from space have grown more and more exacting in terms of the equipment required. As more is discovered, seemingly, more is left to be discovered and ever more sensitive instruments are demanded. Greater sensitivity usually requires large collecting areas, cooled telescopes or massive detectors, all strong factors in determining the mass of the payload. In the fields of Astronomy and Earth Observation the scientific problems seem best tackled by ‘Observatory Class’ missions in which a payload of five or ten separate instruments is compiled to provide the varied individual measurements necessary to address the mission objectives. In some cases these instruments could be launched on separate platforms if their observations could be properly coordinated, in other cases the full set of measurements must be simultaneous in space and time. Launch vehicles which are principally designed to meet the growing needs of geostationary communications satellites are available with the lift capability of many tonnes and so there has been little pressure to identify missions which can achieve the highest quality science from small, and hence inexpensive, satellites.