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Background Population ageing is a global challenge and understanding the dynamics of living arrangements in later life and their implications for the design of appropriate housing and long-term care is a critical policy issue. Existing research has focused on the study of transitions into residential care in the UK. This paper investigates transitions into sheltered accommodation among older people in England and Wales between 1993 and 2008. Methods The study uses longitudinal data constructed from pooled observations across waves 2-18 of the British Household Panel Survey (BHPS) data, focusing on individuals aged 65 and over who lived in private housing at baseline and who were observed for two consecutive time points. A discrete-time logistic regression model was used to examine the association of transitioning into sheltered accommodation with a range of demographic, health and socioeconomic predictors. Results Demographic (age, region), socioeconomic factors (housing tenure, having a washing machine) and contact with health professionals (number of visits to the general practitioner, start in use of health visitor) were significant determinants of an older person's move into sheltered accommodation. Conclusions Transitions into sheltered accommodation are associated with a range of demographic and socioeconomic characteristics as well as service use but not with health. Such results indicate that this type of housing option may be accessible by individuals with relatively good health, but may be limited to those who are referred by gatekeepers. Policymakers could consider making such housing option available to everyone, as well as providing incentives for building lifecourse-sensitive housing in the future. [ABSTRACT FROM AUTHOR]

Introduction Unintentional injuries to children in the outdoors have a significant impact on child mortality, development and healthcare costs. This paper presents the findings of a systematic review about the effectiveness of programs that provided information, advice or education about the prevention of unintentional injuries to children under 15 years during outdoor play and leisure. Methods A structured search strategy was conducted in a range of databases. All report titles and abstracts were screened using pre-defined criteria. Included reports were quality appraised using a modified Graphical Appraisal Tool for Epidemiological studies (GATE) tool. All quality appraisals and data extraction were checked by a second reviewer. If not provided in the original reports, ORs and mean differences were calculated, where sufficient data were available. Results Twenty-three studies met the inclusion criteria. There was a paucity of robust study designs. The majority of studies only reported a short-term follow-up of intermediate outcome measures. Only two studies measured injury rates; both reported a reduction, but both studies also had considerable methodological weaknesses. The five studies that measured the use of protective equipment reported mixed results, although there is some evidence that suggests that more extensive educational programs (such as health fairs and media campaigns) increase their use. The 20 studies that measured behaviour, attitude or knowledge outcomes reported highly mixed results. Discussion Methodological weaknesses of the included studies limit support for a particular course of action. To better inform policy and practice, future research should (1) use robust study designs and (2) not rely on short-term proxy outcome measures. [ABSTRACT FROM AUTHOR]

Background: Following centralisation of UK paediatric intensive care units in 1997, specialist paediatric intensive care retrieval teams (PICRTs) were established to transport critically ill children from district general hospitals (DGHs). The current location and catchment area of PICRTs covering England and Wales are based on historical referral patterns. National quality standards specify that PICRTs should reach the patient bedside within 3 hours of accepting a referral.Objective: To determine what proportion of demand for PICRT services in England and Wales can be reached within 3 hours and to explore the potential coverage impact of more stringent 'time to bedside' standards.Methods: We used mathematical location-allocation methods to: (1) determine the optimal allocation of DGHs to current PICRT locations to minimise road journey time and calculated the proportion of demand reachable within 3 hours, 2 hours, 90 min, 75 min and 1 hour and (2) explore the impact of changing the number and location of PICRTs on demand coverage for the different time thresholds.Results: For current (and optimal) location of 11 PICRTs, 98% (98%) of demand is reachable within 3 hours; 86% (91%) within 2 hours; 59% (69%) within 90 min; 33% (39%) within 75 min; and 20% (20%) within 1 hour. Five hospitals were not reachable within 3 hours. For the 3-hour standard, eight optimally located PICRT locations had similar coverage as the current 11 locations.Conclusions: If new evidence supports reduction in the time to bedside standard, many more hospitals will not be adequately covered. Location-allocation optimisation is a powerful technique for supporting evidence-based service configuration. [ABSTRACT FROM AUTHOR]

Background In recent decades, labour market participation has fallen in men, with large amounts of this decline accounted for by increases in permanent sickness. There is speculation that the rising numbers of permanently sick incorporate more people with less severe conditions than was previously the case. This paper examines the relationship between labour market position and subsequent mortality around State Pension Age. Methods Using linked census and death records in the ONS Longitudinal Study, samples of men aged 55-69 and women aged 50-64 were selected from each decennial census, 1971-2001 and their health followed up. Differences between the employed, unemployed and economically inactive in age-specific death rates, Standardised Mortality Ratios and odds of reporting limiting long-term illness were examined. Results Labour market activity in late middle age has changed since 1971. For example, the proportion of men employed at ages 60-64 years has fallen by 39%, and the proportion permanently sick has more than doubled. Despite this change, there has been stability in the RR of mortality between labour market positions. Working people have the lowest risk of premature death, while, relative to working people, the permanently sick continue to have mortalities around three times higher among men and four to five times higher among women. Conclusion The evidence does not support the notion that the permanently sick are becoming less seriously ill. The persistence of the group's raised mortality suggests that measures aimed at encouraging later life employment should ensure provision of work environments suitable for people with chronic illnesses. [ABSTRACT FROM AUTHOR]

It is impossible to be certain, but it is estimated that each year in England and Wales there may be about 30-40 infant deaths from covert homicide, which represents about 10% of the current annual total of sudden unexpected deaths in infancy. This paper reviews the features that have been suggested as possible indicators of covert homicide, describes the difficulties in its identification and the need for better evidence, and emphasizes the importance of thorough medical investigation of all sudden infant deaths. [ABSTRACT FROM AUTHOR]

STUDY QUESTION: Is the 2000 benchmark for revision rates for both total hip replacement and resurfacing arthroplasty in England and Wales of 10% at 10 years optimal? SUMMARY ANSWER: The revision rate benchmark should be at least halved from 10% at 10 years to 5% at 10 years. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Revision rates vary between different types of total hip replacement device. Data up to 2012 showed that 10 year revision rates were less than 5% for five frequently used categories of device, and revision rates were higher for men than for women. [ABSTRACT FROM AUTHOR]

Objectives: To explore the experiences of clinical leads in paediatric critical care units (PCCUs) in England and Wales during the reorganisation of services in the initial surge of the SARS-CoV-2 pandemic and to learn lessons for future surges and service planning.Methods: A qualitative study design using semistructured interviews via virtual conferencing was conducted with consultant clinical leads and lead nurses covering 21 PCCUs. Interviews were conducted over a period of 2 weeks, 2 months after the initial SARS-CoV-2 surge. Interview notes underwent thematic analysis.Results: Thematic analysis revealed six themes: leadership, management and planning; communication; workforce development and training; innovation; workforce experience; and infection prevention and control. Leadership was facilitated through clinician-led local autonomy for decision-making and services were better delivered when the workforce was empowered to be flexible in their response. Communication was preferred through collaborative management structures. Further lessons include recognising workforce competencies in surge preparations, the use of virtual technology in facilitating training and meetings, the importance of supporting the well-being of the workforce and the secondary consequences of personal protective equipment use.Conclusions: During the 2020 SARS-CoV-2 pandemic, an agile response to a rapidly changing situation was enabled through effective clinical leadership and an adaptive workforce. Open systems of communication across senior clinical and management teams facilitated service planning. Support for all members of the workforce through implementation of appropriate and innovative education and well-being solutions was vital in sustaining resilience. This learning supports planning for future surge capacity across paediatric critical care locally and nationally. [ABSTRACT FROM AUTHOR]

Background: The COPD Best Practice Tariff (BPT) is a pay-for-performance scheme in England that incentivises review by a respiratory specialist within 24 hours of admission and completion of a list of key care components prior to discharge, known as a discharge bundle, for patients admitted with acute exacerbation of COPD (AECOPD). We investigated whether the two components of the COPD BPT were associated with lower 30-day mortality and readmission in people discharged following AECOPD.Methods: Longitudinal study of national audit data containing details of AECOPD admissions in England and Wales between 01 February 2017 and 13 September 2017. Data were linked with national admissions and mortality data. Mixed-effects logistic regression, using a random intercept for hospital to adjust for clustering of patients, was used to determine the relationship between the COPD BPT criteria (combined and separately) and 30-day mortality and readmission. Models were adjusted for age, sex, socioeconomic status, length of stay, smoking status, Charlson comorbidity index, mental illness and requirement for oxygen or noninvasive ventilation during admission.Results: 28 345 patients discharged from hospital following AECOPD were included. 37% of admissions conformed to the two COPD BPT criteria. No relationship was observed between BPT conforming admissions and 30-day mortality (OR: 1.09 (95% CI 0.92 to 1.29)) or readmissions (OR: 0.96 (95% CI 0.90 to 1.02)). No relationship was observed between either of the individual COPD BPT components and 30-day mortality or readmissions. However, a specialist review at any time during admission was associated with lower inpatient mortality (OR: 0.69 (95% CI 0.58 to 0.81)).Conclusion: Completion of the combined COPD BPT criteria does not appear associated with a reduction in 30-day mortality or readmission. However, specialist review was associated with reduced inpatient mortality. While it is difficult to argue that discharge bundles do not improve care, this analysis questions whether the pay-for-performance model improves mortality or readmissions. [ABSTRACT FROM AUTHOR]

Background and objective The impact of the COVID-19 pandemic on the quality of care for patients with acute myocardial infarction (AMI) is uncertain. We aimed to compare quality of AMI care in England and Wales during and before the COVID-19 pandemic using the 2020 European Society of Cardiology Association for Acute Cardiovascular Care quality indicators (QIs) for AMI. Methods Cohort study of linked data from the AMI and the percutaneous coronary intervention registries in England and Wales between 1 January 2017 and 27 May 2020 (representing 236 743 patients from 186 hospitals). At the patient level, the likelihood of attainment for each QI compared with pre COVID-19 was calculated using logistic regression. The date of the first national lockdown in England and Wales (23 March 2020) was chosen for time series comparisons. Results There were 10 749 admissions with AMI after 23 March 2020. Compared with before the lockdown, patients admitted with AMI during the first wave had similar age (mean 68.0 vs 69.0 years), with no major differences in baseline characteristics (history of diabetes (25% vs 26%), renal failure (6.4% vs 6.9%), heart failure (5.8% vs 6.4%) and previous myocardial infarction (22.9% vs 23.7%)), and less frequently had high Global Registry of Acute Coronary Events risk scores (43.6% vs 48.6%). There was an improvement in attainment for 10 (62.5%) of the 16 measured QIs including a composite QI (43.8% to 45.2%, OR 1.06, 95% CI 1.02 to 1.10) during, compared with before, the lockdown. Conclusion During the first wave of the COVID-19 pandemic in England and Wales, quality of care for AMI as measured against international standards did not worsen, but improved modestly. [ABSTRACT FROM AUTHOR]

The article summarizes a study evaluating the relation between high ambient temperatures with the changes in the risk of myocardial infarction on an hourly timescale. Paper-adds including data at an hourly temporal resolution from 11 conurbations in England and Wales showed that higher temperatures were associated with increased risk of myocardial infarction, with reductions in risk at longer lags being consistent with heat, in the six hours after exposure, above a threshold of 20°C.

BACKGROUND: Data are limited on the proportion of stroke patients nationally appropriate for thrombolysis either within the 3 h time window or the recently tested 4.5 h. This information is important for the redesign of services. METHODS: Data on case mix, eligibility for thrombolysis, treatment and outcomes were extracted from the National Sentinel Stroke 2008 Audit dataset. This contains retrospective data on up to 60 consecutive stroke admissions from each acute hospital in England, Wales and Northern Ireland between 1 April and 30 June 2008. FINDINGS: All relevant hospitals participated, submitting data on 11 262 acute stroke patients. 2118 patients arrived within 2 h and 2596 within 3 h of the onset of symptoms and 587 people were already in hospital. Therefore, 28% (3183) were potentially eligible for thrombolysis based on a 3 h time criterion. Of these, 1914 were under 80 years and 2632 had infarction with 14% (1605) meeting all three National Institute of Neurological Disorders and Stroke study criteria and so being potentially eligible for thrombolysis. If the time window is increased to 4.5 h then only another 2% became eligible. If the age limit was removed for treatment, the percentage potentially appropriate for tissue plasminogen activator increased to 23% within 3 h and 26% within 4.5 h. Overall, 1.4% (160) of patients were thrombolysed. INTERPRETATION: Thrombolysis rates are currently low in the UK. 14% of patients in this sample were potentially suitable for thrombolysis using the 3 h time window. This would only increase marginally if thrombolysis was extended to include those up to 4.5 h. The greatest impact on increasing the proportion of patients suitable for thrombolysis would be to increase the number of patients presenting early and by demonstrating that the treatment is safe and effective in patients over 80 years of age. [ABSTRACT FROM AUTHOR]

This article focuses on the evaluation of National Congenial Anomaly System (NCAS) in England and Wales. The problems with NCAS are well described in the papers--very poor ascertainment, and no data on antenatally diagnosed cases, except when fed data by the regional congenital anomaly registers; massively incomplete data fields; and consequently a severely limited capacity to fulfill the role for which it was set up in the wake of the thalidomide disaster. Yet congenital anomaly remains a leading cause of death and disability, perinatally and in infancy. It continues to pose challenges to public health, neonatal medicine and surgery.

Objectives: To determine whether clinical signs and symptoms of osteoarthritis influence general practitioners' (GPs) decisions about x raying older patients with knee pain and whether x ray reports alter their initial treatment or referral plan.Methods: A cross sectional survey of 1000 GPs in England and Wales using "paper cases" in three questionnaires mailed at two-weekly intervals. The first questionnaire assessed GPs' management of patients with knee pain using four case scenarios, two with features of clinical knee osteoarthritis. The second questionnaire contained the same scenarios with information on x ray findings added. The third questionnaire considered management of knee pain in general.Results: 447 GPs responded to questionnaire 1, 316 (71%) to questionnaire 2, 287 (64%) to questionnaire 3. 106 responders (25%) would have x rayed all four patients and 64 (15%) none. Choosing to carry out an x ray examination was not influenced by the presence of clinical signs and symptoms of osteoarthritis but was linked to other management choices, such as referral to orthopaedics (odds ratio (OR) 2.13; 95% confidence interval (CI) 1.62 to 2.81). The strongest predictor in questionnaire 2 of a treatment or referral was whether it had been chosen in the first survey. However, the x ray report was associated with a significant change in treatment and referrals. Where radiographic osteoarthritis was present, GPs were less likely to refer to a physiotherapist (OR 0.64; 95% CI 0.50 to 0.83) or rheumatologist (OR 0.15; 95% CI 0.08 to 0.28), and more likely to refer to an orthopaedic surgeon (OR 31.34; 95% CI 21.51 to 45.66). Questionnaire 3 showed that GPs' general views on the use of x rays correlated with the frequency of their choosing to x ray in the four individual case scenarios.Conclusions: A GP's choice to x ray older people with knee symptoms is linked with decisions on treatment and referral even before the x ray result is known, but it does not appear to be influenced by clinical features of osteoarthritis. The presence of radiographic osteoarthritis has a marked impact on the decision to refer to secondary care. More evidence on the outcome of management without x rays is needed to help GPs in decision making. [ABSTRACT FROM AUTHOR]

Background and Objective Several studies report poorer quality healthcare for patients presenting at weekends. Our objective was to examine how timely surgery for patients with hip fracture varies with day and time of their presentation. Methods This population- based cohort study used 2017 data from the National Hip Fracture Database, which recorded all patients aged 60 years and over who presented with a hip fracture at a hospital in England, Wales and Northern Ireland. Provision of prompt surgery (surgery within 36 hours of presentation) was examined, using multivariable logistic regression with generalised estimating equations to derive adjusted risk ratios (RRs). Time was categorised into three 8- hour intervals (day: 08:00-15:59, evening: 16:00-23:59 and night: 00:00-07:59) for each day of the week. The model accounted for clustering by hospital and was adjusted by sex, age, fracture type, operation type, American Society of Anesthesiologists grade, preinjury mobility and location. Results We studied 68 977 patients from 177 hospitals. The average patient presenting during the day on Friday or Saturday was significantly less likely to undergo prompt surgery (Friday during 08:00-15:59, RR=0.93, 95% CI 0.91 to 0.96; Saturday during 08:00-15:59, RR=0.91, 95% CI 0.88 to 0.94) than patients in the comparative category (Thursday, during the day). Patients presenting during the evening (16:00-23:59) were consistently significantly less likely to undergo prompt surgery, and the effect was more marked on Fridays and Saturdays (Friday during 16:00-23:59, RR=0.83, 95% CI 0.80 to 0.85; Saturday during 16:00-23:59, RR=0.81, 95% CI 0.78 to 0.85). Patients presenting overnight (00:00-07:59), except on Saturdays, were significantly more likely to undergo surgery within 36 hours (RR>1.07). Conclusion The provision of prompt hip fracture surgery was complex, with evidence of both an 'evening' and a 'night' effect. Investigation of weekly variation in hip fracture care is required to help implement strategies to reduce the variation in timely surgery throughout the entire week. [ABSTRACT FROM AUTHOR]

Objectives To evaluate whether distance and estimated travel time to hospital for patients undergoing emergency laparotomy is associated with postoperative mortality. Design National cohort study using data from the National Emergency Laparotomy Audit. Setting 171 National Health Service hospitals in England and Wales. Participants 22 772 adult patients undergoing emergency surgery on the gastrointestinal tract between 2013 and 2016. Main outcome measures Mortality from any cause and in any place at 30 and 90 days after surgery. Results Median on-road distance between home and hospital was 8.4 km (IQR 4.7-16.7 km) with a median estimated travel time of 16 min. Median time from hospital admission to operating theatre was 12.7 hours. Older patients live on average further from hospital and patients from areas of increased socioeconomic deprivation live on average less far away. We included estimated travel time as a continuous variable in multilevel logistic regression models adjusting for important confounders and found no evidence for an association with 30-day mortality (OR per 10 min of travel time=1.02, 95% CI 0.97 to 1.06, p=0.512) or 90-day mortality (OR 1.02, 95 % CI 0.97 to 1.06, p=0.472). The results were similar when we limited our analysis to the subgroup of 5386 patients undergoing the most urgent surgery. 30-day mortality: OR=1.02 (95% CI 0.95 to 1.10, p=0.574) and 90-day mortality: OR=1.01 (95% CI 0.94 to 1.08, p=0.858). Conclusions In the UK NHS, estimated travel time between home and hospital was not a primary determinant of short-term mortality following emergency gastrointestinal surgery. [ABSTRACT FROM AUTHOR]

The article presents comments on a paper by researcher N. Khairulddin and colleagues titled "Emergence of Methicillin Resistant Staphylococcus Aureus," published in the April 2004 issue of the journal "Archives of Disease in Childhood." Khairulddiri and colleagues reported the proportion of bacteraemias with Staphylococcus aureus in children in England and Wales that were due to Methicillin Resistant Staphylococcus Aureus (MRSA.), which increased from 0.9% to 13.1% between 1990 and 2000. The author and researchers point out that there is an urgent need for a national review of MRSA in children, both to establish the extent of the current problem and to implement infection control measures.

The article reports on the decision by the Care Standards Tribnunal of England and Wales in 2015 to uphold the ruling by the Care Quality Commission (CQC) to suspend the general practice of Mujib ul Haq Khan due to concerns about patient safety.

Objective: To describe ethnic and socioeconomic variation in cause-specific infant mortality of preterm babies by gestational age at birth.Design: National birth cohort study.Setting: England and Wales 2006-2012.Subjects: Singleton live births at 24-36 completed weeks' gestation (n=256 142).Outcome Measures: Adjusted rate ratios for death in infancy by cause (three groups), within categories of gestational age at birth (24-27, 28-31, 32-36 weeks), by baby's ethnicity (nine groups) or area deprivation score (Index of Multiple Deprivation quintiles).Results: Among 24-27 week births (5% of subjects; 47% of those who died in infancy), all minority ethnic groups had lower risk of immaturity-related death than White British, the lowest rate ratios being 0.63 (95% CI 0.49 to 0.80) for Black Caribbean, 0.74 (0.64 to 0.85) for Black African and 0.75 (0.60 to 0.94) for Indian. Among 32-36 week births, all minority groups had higher risk of death from congenital anomalies than White British, the highest rate ratios being 4.50 (3.78 to 5.37) for Pakistani, 2.89 (2.10 to 3.97) for Bangladeshi and 2.06 (1.59 to 2.68) for Black African; risks of death from congenital anomalies and combined rarer causes (infection, intrapartum conditions, SIDS and unclassified) increased with deprivation, the rate ratios comparing the most with the least deprived quintile being, respectively, 1.54 (1.22 to 1.93) and 2.05 (1.55 to 2.72). There was no evidence of socioeconomic variation in deaths from immaturity-related conditions.Conclusions: Gestation-specific preterm infant mortality shows contrasting ethnic patterns of death from immaturity-related conditions in extremely-preterm babies, and congenital anomalies in moderate/late-preterm babies. Socioeconomic variation derives from congenital anomalies and rarer causes in moderate/late-preterm babies. Future research should examine biological origins of extremely preterm birth. [ABSTRACT FROM AUTHOR]

Objectives: To construct UK ethnicity birth weight centiles (UK-EBWC) for gestational age and cut-offs for small for gestational age (SGA) for England and Wales and to evaluate the SGA misclassification using the UK centiles.Design: Analysis of national birth data.Participants: All live singleton births in England and Wales in 2006-2012, as recorded by the Office for National Statistics and birth registrations, linked with National Health Service into numbers for babies.Main Outcome Measures: Both sex-specific and ethnicity-sex-specific birth weight centiles for gestational age, and ethnicity-sex-specific SGA cut-offs. Centiles were computed using the generalised additive model for location, scale and shape.Results: Our sex-specific centiles performed well and showed an agreement between the expected and observed number of births below the centiles. The ethnicity-sex-specific centiles for Black and Asian presented lower values compared with the White centiles. Comparisons of sex-specific and ethnicity-sex-specific centiles shows that use of sex-specific centiles increases the SGA diagnosed cases by 50% for Asian, 30% for South Asian (Indian, Pakistani and Bangladeshi) and 20% for Black ethnicity.Conclusions: The centiles show important differences between ethnic groups, in particular the 10th centile used to define SGA. To account for these differences and to minimise misclassification of SGA, we recommend the use of customised birth weight centiles. [ABSTRACT FROM AUTHOR]

Aims: To describe the nature and causes of patient safety incidents relating to care at home for children with enteral feeding devices.Methods: We analysed incident data relating to paediatric nasogastric, gastrostomy or jejunostomy feeding at home from England and Wales' National Reporting and Learning System between August 2012 and July 2017. Manual screening by two authors identified 274 incidents which met the inclusion criteria. Each report was descriptively analysed to identify the problems in the delivery of care, the contributory factors and the patient outcome.Results: The most common problems in care related to equipment and devices (n=98, 28%), procedures and treatments (n=86, 24%), information, training and support needs of families (n=54, 15%), feeds (n=52, 15%) and discharge from hospital (n=31, 9%). There was a clearly stated harm to the child in 52 incidents (19%). Contributory factors included staff/service availability, communication between services and the circumstances of the family carer.Conclusions: There are increasing numbers of children who require specialist medical care at home, yet little is known about safety in this context. This study identifies a range of safety concerns relating to enteral feeding which need further investigation and action. Priorities for improvement are handovers between hospital and community services, the training of family carers, the provision and expertise of services in the community, and the availability and reliability of equipment. Incident reports capture a tiny subset of the total number of adverse events occurring, meaning the scale of problems will be greater than the numbers suggest. [ABSTRACT FROM AUTHOR]

The author comments on a study which assesses the long term effect of Great Britain legislation introduced in September 1998 to restrict pack sizes of paracetamol on deaths from paracetamol poisoning and liver unit activity. The author highlights that the legislation to reduce pack sizes of paracetamol was followed by significant reductions in deaths due to paracetamol overdose. The author opines that considering the continuing toll of deaths further preventive measures should be sought.

Aim: To investigate sex differences in acute myocardial infarction (AMI) guideline-indicated care as defined by the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) quality indicators.Methods: Nationwide cohort study comprising 691 290 AMI hospitalisations in England and Wales (n=233 hospitals) from the Myocardial Ischaemia National Audit Project between 1 January 2003 and 30 June 2013.Results: There were 34.5% (n=238 489) women (median age 76.7 (IQR 66.3-84.0) years; 33.9% (n=80 884) ST-elevation myocardial infarction (STEMI)) and 65.5% (n=452 801) men (median age 67.1 (IQR 56.9-77.2) years; 42.5% (n=192 229) STEMI). Women less frequently received 13 of the 16 quality indicators compared with men, including timely reperfusion therapy for STEMI (76.8% vs 78.9%; p<0.001), timely coronary angiography for non-STEMI (24.2% vs 36.7%; p<0.001), dual antiplatelet therapy (75.4% vs 78.7%) and secondary prevention therapies (87.2% vs 89.6% for statins, 82.5% vs 85.6% for ACE inhibitor/angiotensin receptor blockers and 62.6% vs 67.6% for beta-blockers; all p<0.001). Median 30-day Global Registry of Acute Coronary Events risk score adjusted mortality was higher for women than men (median: 5.2% (IQR 1.8%-13.1%) vs 2.3% (IQR 0.8%-7.1%), p<0.001). An estimated 8243 (95% CI 8111 to 8375) deaths among women could have been prevented over the study period if their quality indicator attainment had been equal to that attained by men.Conclusion: According to the ESC ACCA AMI quality indicators, women in England and Wales less frequently received guideline-indicated care and had significantly higher mortality than men. Greater attention to the delivery of recommended AMI treatments for women has the potential to reduce the sex-AMI mortality gap. [ABSTRACT FROM AUTHOR]

The article reports on the Royal College of Surgeons' consultation paper "Delivering High-Quality Surgical Services for the Future." The group recommended that surgeons in England and Wales form a network and work as teams in a specific area, rather than for the individual NHS hospital trusts. The consultation paper also focused on surgical training standards. The College's president, Bernard Ribeiro, comments on health service policy.

Objective: To describe the long-term outcomes, treatment pathways and risk factors for patients diagnosed with hypoplastic left heart syndrome (HLHS) in England and Wales.Methods: The UK's national audit database captures every procedure undertaken for congenital heart disease and updated life status for resident patients in England and Wales. Patients with HLHS born between 2000 and 2015 were identified using codes from the International Paediatric and Congenital Cardiac Code.Results: There were 976 patients with HLHS. Of these, 9.6% had a prepathway intervention, 89.5% underwent a traditional pathway of staged palliation and 6.4% of infants underwent a hybrid pathway. Patients undergoing prepathway procedures or the hybrid pathway were more complex, exhibiting higher rates of prematurity and acquired comorbidity. Prepathway intervention was associated with the highest in-hospital mortality (34.0%).44.6% of patients had an off-pathway procedure after their primary procedure, most frequently stenting or dilation of residual or recoarctation and most commonly occurring between stage 1 and stage 2.The survival rate at 1 year and 5 years was 60.7% (95% CI 57.5 to 63.7) and 56.3% (95% CI 53.0 to 59.5), respectively. Patients with an antenatal diagnosis (multivariable HR (MHR) 1.63 (95% CI 1.12 to 2.38)), low weight (<2.5 kg) (MHR 1.49 (95% CI 1.05 to 2.11)) or the presence of an acquired comorbidity (MHR 2.04 (95% CI 1.30 to 3.19)) were less likely to survive.Conclusion: Treatment pathways among patients with HLHS are complex and variable. It is essential that the long-term outcomes of conditions like HLHS that require serial interventions are studied to provide a fuller picture and to inform quality assurance and improvement. [ABSTRACT FROM AUTHOR]

Life-extending treatment, in the form of artificial nutrition and hydration, is often provided to people in permanent vegetative states (PVS) in England and Wales for many years, even when their family believes the patient would not want it and despite the fact that no court in the UK has ever found in favour of continuing such treatment for a patient with a confirmed PVS diagnosis. The first half of this article presents a close analysis of the recent case of Cumbria NHS Clinical Commissioning Group v Miss S and Ors [2016] EWCOP 32. It examines the causes of delay in bringing this case to court and reaching a final judgment. It draws not only on the published judgment, but also on the two authors' involvement in supporting the family (before, during and subsequent to the court hearings) as a result of their academic and policy-related work in this area. This includes conversations with the family and with members of the clinical and legal teams, and observations in court. The second part of the article draws out the ethical and practical implications of the findings for theory and policy and suggests ways forward in relation to (a) the provision and inspection of care for these patients; (b) legal practice in relation to 'best interests' and (c) the perceived requirement under English law for a court application before life-prolonging treatment can be withdrawn from PVS patients-even in the absence of any 'in principle' opposition. [ABSTRACT FROM AUTHOR]

Background: Pulmonary rehabilitation (PR) improves exercise capacity and health status in patients with COPD, but many patients assessed for PR do not complete therapy. It is unknown whether socioeconomic deprivation associates with rates of completion of PR or the magnitude of clinical benefits bequeathed by PR.Methods: PR services across England and Wales enrolled patients to the National PR audit in 2015. Deprivation was assessed using Index of Multiple Deprivation (IMD) derived from postcodes. Study outcomes were completion of therapy and change in measures of exercise performance and health status. Univariate and multivariate analyses investigated associations between IMD and these outcomes.Results: 210 PR programmes enrolled 7413 patients. Compared with the general population, the PR sample lived in relatively deprived neighbourhoods. There was a statistically significant association between rates of completion of PR and quintile of deprivation (70% in the least and 50% in the most deprived quintiles). After baseline adjustments, the risk ratio (95% CI) for patients in the most deprived relative to the least deprived quintile was 0.79 (0.73 to 0.85), p<0.001. After baseline adjustments, IMD was not significantly associated with improvements in exercise performance and health status.Conclusions: In a large national dataset, we have shown that patients living in more deprived areas are less likely to complete PR. However, deprivation was not associated with clinical outcomes in patients who complete therapy. Interventions targeted at enhancing referral, uptake and completion of PR among patients living in deprived areas could reduce morbidity and healthcare costs in such hard-to-reach populations. [ABSTRACT FROM AUTHOR]