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The LACE index scoring tool has been designed to predict hospital readmissions in adults. We aimed to evaluate the ability of the LACE index to identify children at risk of frequent readmissions. We analysed data from alive-discharge episodes (1 April 2017 to 31 March 2019) for 6546 males and 5875 females from birth to 18 years. The LACE index predicted frequent all-cause readmissions within 28 days of hospital discharge with high accuracy: the area under the curve = 86.9% (95% confidence interval = 84.3–89.5%, p < 0.001). Two-graph receiver operating characteristic curve analysis revealed the LACE index cutoff to be 4.3, where sensitivity equals specificity, to predict frequent readmissions. Compared with those with a LACE index score = 0–4 (event rates, 0.3%), those with a score > 4 (event rates, 3.7%) were at increased risk of frequent readmissions: age- and sex-adjusted odds ratio = 12.4 (95% confidence interval = 8.0–19.2, p < 0.001) and death within 30 days of discharge: OR = 5.0 (95% CI = 1.5–16.7). The ORs for frequent readmissions were between 6 and 14 for children of different age categories (neonate, infant, young child and adolescent), except for patients in the child category (6–12 years) where odds ratio was 2.8. Conclusion: The LACE index can be used in healthcare services to identify children at risk of frequent readmissions. Focus should be directed at individuals with a LACE index score above 4 to help reduce risk of readmissions. What is Known: • The LACE index scoring tool has been widely used to predict hospital readmissions in adults. What is New: • Compared with children with a LACE index score of 0–4 (event rates, 0.3%), those with a score > 4 are at increased risk of frequent readmissions by 14-fold. • The cutoff of a LACE index of 4 may be a useful level to identify children at increased risk of frequent readmissions. [ABSTRACT FROM AUTHOR]

Purpose: With improving nutrition and health, athletes have grown taller and heavier over the past century. Since there is no weight restriction in the heavyweight class, secular changes in anthropometric measurements of heavyweight boxers may mirror those of contemporary general populations. Objectives: We aimed to (1) examine secular trends in adiposity and musculoskeletal measurements in heavyweight boxers, (2) determine anthropometric differences between champions and unsuccessful challengers. Methods: Detailed demographics taken at time of contest (first official World Championship to current contest: 1889–2019) were collected from media archives. Results: All 237 boxers (83 champions, 154 challengers) contesting a recognised heavyweight World Championships were identified. They had mean (± SD) age = 28.9 ± 4.1 years, height = 187.3 ± 6.5 cm, reach = 195.2 ± 9.4 cm, weight = 97.5 ± 11.5 kg, BMI = 27.8 ± 2.4 kg/m2 and waist = 87.9 ± 6.2 cm. Contest years explained 25.9% (p < 0.001) of the variance in BMI for champions and 30.9% (p < 0.001) for challengers, 9.1% (p < 0.071) in WC for champions and 19.9% (p < 0.001) for challengers. Contest years correlated with height (r = 0.531, p < 0.001), reach (r = 0.341, p < 0.001), weight (r = 0.603, p < 0.001) and BMI (r = 0.370, p = 0.001) among all documented boxers, and with waist only in challengers (r = 0.349, p < 0.001) but not in champions (r = 0.078, p = 0.509). Compared with challengers, champions had greater stature by + 3.4 cm (p < 0.001), reach + 3.6 cm (p = 0.005) and weight + 3.7 kg (p = 0.017), with similar BMI and waist. Champions had larger biceps and forearms but did not differ from challengers in other musculoskeletal dimensions. Conclusions: Over 130 years elite heavyweight boxers have increased in size (BMI) and reach but waists in champions have remained static. Being heavier, taller with longer and bigger arms, but with similar in BMI and waist, appear to be differentiating factors between champions and challengers. [ABSTRACT FROM AUTHOR]

Introduction: Parkinson's disease (PD) is managed primarily by dopamine agonists and physiotherapy while virtual reality (VR) has emerged recently as a complementary method. The present study reviewed the effectiveness of VR in rehabilitation of patients with PD.Methods: Literature search up to June 2019 identified ten studies (n = 343 participants) suitable for meta-analysis and 27 studies (n = 688 participants) for systematic review. Standard mean difference (SMD) and 95% confidence intervals (CI) were calculated using a random effects model.Results: In meta-analysis, compared with active rehabilitation intervention, VR training led to greater improvement of stride length, SMD = 0.70 (95%CI = 0.32-1.08, p = 0.0003), and was as effective for gait speed, balance and co-ordination, cognitive function and mental health, quality of life and activities of daily living. Compared with passive rehabilitation intervention, VR had greater effects on balance: SMD = 1.02 (95%CI = 0.38-1.65, p = 0.002). Results from single randomised controlled trials showed that VR training was better than passive rehabilitation intervention for improving gait speed SMD = 1.43 (95%CI = 0.51-2.34, p = 0.002), stride length SMD = 1.27 (95%CI = 0.38-2.16, p = 0.005) and activities of daily living SMD = 0.96 (95%CI = 0.02-1.89). Systematic review showed that VR training significantly (p < 0.05) improved motor function, balance and co-ordination, cognitive function and mental health, and quality of life and activities of daily living.Conclusion: VR used in rehabilitation for patients with PD improves a number of outcomes and may be considered for routine use in rehabilitation. [ABSTRACT FROM AUTHOR]

Background: The influences of genetic variants on functional clinical outcomes following stroke are unclear. In order to reliably quantify these influences, we undertook a comprehensive meta-analysis of outcomes after acute intracerebral haemorrhage (ICH) or ischaemic stroke (AIS) in relation to different genetic variants.Methods: PubMed, PsycInfo, Embase and Medline electronic databases were searched up to January 2019. Outcomes, defined as favourable or poor, were assessed by validated scales (Barthel index, modified Rankin scale, Glasgow outcome scale and National Institutes of Health stroke scale).Results: Ninety-two publications comprising 31,895 cases met our inclusion criteria. Poor outcome was observed in patients with ICH who possessed the APOE4 allele: OR =2.60 (95% CI = 1.25-5.41, p = 0.01) and in AIS patients with the GA or AA variant at the BDNF-196 locus: OR = 2.60 (95% CI = 1.25-5.41, p = 0.01) or a loss of function allele of CYP2C19: OR = 2.36 (95% CI = 1.56-3.55, p < 0.0001). Poor outcome was not associated with APOE4: OR = 1.02 (95% CI = 0.81-1.27, p = 0.90) or IL6-174 G/C: OR = 2.21 (95% CI = 0.55-8.86, p = 0.26) in patients with AIS.Conclusions: We demonstrate that recovery of AIS was unfavourably associated with variants of BDNF and CYP2C19 genes whilst recovery of ICH was unfavourably associated with APOE4 gene. [ABSTRACT FROM AUTHOR]

Background: Urgent reversal of vitamin K antagonists (VKAs) is required for major bleeding or urgent surgery by intravenous vitamin K with either prothrombin complex concentrates (PCCs) or fresh frozen plasma (FFP). However, there is lack of consensus regarding the superiority of either reversal agent. We sought to compare the performance of PCC and FFP in urgent reversal of VKA. Methods: A meta-analysis was conducted up to November 2018. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. Results: Seventeen studies comprising 2606 participants met the inclusion criteria. Compared with FFP treatment, PCC treatment led to a reduction in 90-day all-cause mortality (OR 0.60, 95% CI 0.40–0.90, p = 0.01), better reversal of INR (OR 7.36, 95% CI 4.18–12.98; p < 0.00001) and lower risk of at least one treatment-related adverse event (OR 0.45, 95% CI 0.26–0.80, p = 0.006). Among patients with VKA-associated intracranial haemorrhage, PCC treatment led to a reduction in 90-day all-cause mortality (OR 0.58, 95% CI 0.35–0.94, p = 0.03) and better reversal of INR (OR 6.52, 95% CI 1.66–25.59, p = 0.007). There were no differences between these two agents in thrombogenicity, requirement for and quantity of red blood cell transfusions, all adverse events, fluid overload or disability on discharge or at 90 days. Conclusions: As an agent for urgent reversal of VKA, PCC outperforms FFP in 90-day all-cause mortality including those with VKA-related intracranial haemorrhage, INR reversal and treatment-related adverse events. [ABSTRACT FROM AUTHOR]

Objectives: The National Institute of Health and Clinical Excellence and The Royal College of Physicians recommend transferring thrombolysed patients with stroke to a hyperacute stroke unit (HASU) within 4 h from hospital arrival (TArrival-HASU), but there is paucity of evidence to support this cut-off. We assessed if a shorter interval within this target threshold conferred a significant improvement in patient mortality.Design: We conducted a retrospective analysis of prospectively collected data from the Sentinel Stroke National Audit Programme.Setting: Four major UK hyperacute stroke centres between 2014 and 2016.Participants: A total of 183 men (median age = 75 years, IQR = 66-83) and 169 women (median age = 81 years, IQR = 72.5-88) admitted with acute ischaemic stroke.Main Outcome Measures: We evaluated TArrival-HASU in relation to inpatient mortality, adjusted for age, sex, co-morbidities, stroke severity, time between procedures, time and day on arrival.Results: There were 51 (14.5%) inpatient deaths. On ROC analysis, the AUC (area under the curve) was 61.1% (52.9-69.4%, p = 0.01) and the cut-off of TArrival-HASU where sensitivity equalled specificity was 2 h/15 min (intermediate range = 30 min to 3 h/15 min) for predicting mortality. On logistic regression, compared with the fastest TArrival-HASU group within 2 h/15 min, the slowest TArrival-HASU group beyond upper limit of intermediate range (≥ 3 h/15 min) had an increased risk of mortality: 5.6% vs. 19.6%, adjusted OR = 5.6 (95%CI:1.5-20.6, p = 0.010).Conclusions: We propose three new alarm time zones (A1, A2 and A3) to improve stroke survival: "A1 Zone" (TArrival-HASU < 2 h/15 min) indicates that a desirable target, "A2 Zone" (TArrival-HASU = 2 h/15 min to 3 h/15 min), indicates increasing risk and should not delay any further, and "A3 Zone" (TArrival-HASU ≥ 3 h/15 min) indicates high risk and should be avoided. [ABSTRACT FROM AUTHOR]

Purpose: While weight gain and obesity are the dominant factors, dietary sugar and specifically sugar-sweetened beverages (SSB) has been implicated in causing type 2 diabetes (T2DM). We assessed how much of the apparent effect of SSB is explained by adiposity, but not captured by adjustment for BMI, which is a poor index of body fat. Methods: We examined data from 5187 adults (mean age 50.8 years, SD = 16.4, 172 (3.3%) T2DM), from the Scottish Health Survey 2003 and 2008–2010 databases. Logistic regression was used to assess the association between SSB consumption and T2DM (non-insulin treated) and its attenuation (reduction in odds ratios, ORs), after entering published anthropometric indices of adiposity into the regression model, adjusted for age, sex, social class, education, smoking, alcohol consumption and physical activity. Results: Compared with low SSB categories ("less often/never", once/week or 1–3 times/month), the OR without adiposity adjustment for having T2DM in high SSB consumers (2–3, 4–5, ≥ 6/day) was 2.56 (95% CI 1.12–5.83; p = 0.026). That OR was marginally changed by adjusting for BMI (+ 4.3%), WC (+ 5.5%) or total body fat (− 4.3%), but greatly attenuated by adjusting for estimated %body fat (− 23.4%). These indices had similar influences on the associations between SSB and T2DM combining known T2DM patients with unknown HbA1c > 6.5%, > 48 mmol/mol. Conclusions: Associations between SSB and T2DM are attenuated more markedly by adjustment with estimated %body fat than with BMI, indicating an adiposity effect not captured using BMI. Future research should employ best available estimates of adiposity. [ABSTRACT FROM AUTHOR]

The originally published version of this article contained typesetting errors in Figure 4. [ABSTRACT FROM AUTHOR]

Background: The present study assessed factors associated with the risk of surgical site infections (SSI) after a caesarean section (C-section). Methods: Data were collected in 1682 women undergoing elective (53.9%) and emergency (46.1%) C-sections between 1st August 2020, and 30th December 2021, at a National Health Service hospital (Surrey, UK). Results: At the time of C-section, the mean age was 33.1 yr (SD ± 5.2). Compared to women with BMI < 30 kg/m2, those with a BMI ≥ 35 kg/m2 had a greater risk of SSI, OR 4.07 (95%CI 2.48–6.69). Women with a history of smoking had a greater risk of SSI than those who had never smoked, OR 1.69 (95%CI 1.05–2.27). Women with a BMI ≥ 30 kg/m2 and had a smoking history or emergency C-section had 3- to tenfold increases for these adverse outcomes. Ethnic minority, diabetes or previous C-section did not associate with any of the outcomes. Conclusions: High BMI, smoking, and emergency C-section are independent risk factors for SSI from C-section. Women planning conception should avoid excess body weight and smoking. Women with diabetes and from ethnic minority backgrounds did not have increased risks of SSI, indicating a consistent standard of care for all patients. [ABSTRACT FROM AUTHOR]

Objective: Socioeconomic and health inequalities persist in multicultural western countries. Here, we compared outcomes following an acute stroke amongst ethnic minorities with Caucasian patients. Methods: Data were prospectively collected (2014–2016) from the Sentinel Stroke National Audit Programme for 3309 patients who were admitted with an acute stroke in four UK hyperacute stroke units. Associations between variables were examined by chi-squared tests and multivariable logistic regression, adjusted for age, sex, prestroke functional limitations and co-morbidities, presented as odds ratios (OR) with 95% CI. Results: There were 3046 Caucasian patients, 95 from ethnic minorities (mostly South Asians, Blacks, mixed race and a few in other ethnic groups) and 168 not stated. Compared with Caucasian patients, those from ethnic minorities had a proportionately higher history of diabetes (33.7% vs 15.4%, P < 0.001), but did not differ in other chronic conditions, functional limitations or sex distribution. Their age of stroke onset was younger both in women (76.8 year vs 83.2 year, P < 0.001) and in men (69.5 year vs 75.9 year, P = 0.002). They had greater risk for having a stroke before the median age of 79.5 year: OR = 2.15 (1.36–3.40) or in the first age quartile (< 69 year): OR = 2.91 (1.86–4.54), requiring palliative care within the first 72 h: OR = 3.88 (1.92–7.83), nosocomial pneumonia or urinary tract infection within the first 7 days of admission: OR = 1.86 (1.06–3.28), and in-hospital mortality: OR = 2.50 (1.41–4.44). Conclusions: Compared with Caucasian patients, those from ethnic minorities had earlier onset of an acute stroke by about 5 years and a 2- to fourfold increase in many stroke-related adverse outcomes and death. [ABSTRACT FROM AUTHOR]

Hip fracture in older adults is associated with poor prognosis. We tested the hypothesis that a single standardized measure, pre-fracture mobility, can be used as an early indicator of patients at high health risk after a hip fracture. Analysis of prospectively collected data of older adults admitted with a hip fracture between April-2009 and June-2019 in a single NHS hospital, UK. Pre-fracture mobility status (freely mobile, mobilising outdoors with one aid or with two aids, and limited to indoors), was used to predict length of stay (LOS) and mortality in hospital, and discharge destination. Among 3073 (2231 women, 842 men) admitted from their own home (mean ± SD age = 82.7 ± 9.3 yr), 159 died and 2914 survived to discharge: 1834 back to their home, 772 to rehabilitation, 66 to residential care, 141 to nursing care and 101 to unknown destinations. Compared with LOS of 15.9 ± 15.6 days in patients who mobilised freely before fracture (reference), those who were able to mobilise outdoors with one aid stayed 3.5 days, and those with two aids or confined to indoor mobility stayed one week longer in hospital. In-patient mortality was increased among patients who mobilised outdoors with two aids: OR = 2.1 (95%CI = 1.3–3.3), and those limited to indoors: OR = 2.1 (1.3–1.5). Finally, a change in residence on discharge was more likely in those who mobilised outdoors with two aids (OR = 1.8, 95%CI = 1.2–2.6), and those limited to indoors (OR = 1.9, 95%CI = 1.2–2.9). In conclusion, pre-fracture mobility may be a useful early indicator for identifying patients at increased risk of adverse outcomes after an acute hip fracture. [ABSTRACT FROM AUTHOR]

Objective: Hospital-onset stroke (HOS) is associated with poorer outcomes than community-onset stroke (COS). Previous studies have variably documented patient characteristics and outcome measures; here, we compare in detail characteristics, management and outcomes of HOS and COS.Methods: A total of 1656 men (mean age ± SD = 73.1 years ± 13.2) and 1653 women (79.3 years ± 13.0), with data prospectively collected (2014-2016) from the Sentinel Stroke National Audit Programme, were admitted with acute stroke in four UK hyperacute stroke units (HASU). Associations between variables were examined by chi-squared tests and multivariable logistic regression (COS as reference).Results: There were 272 HOS and 3037 COS patients with mean ages of 80.2 years ± 12.5 and 76.4 years ± SD13.5 and equal sex distribution. Compared to COS, HOS had higher proportions ≥ 80 years (64.0% vs 46.4%), congestive heart failure (16.9% vs 4.9%), atrial fibrillation (25.0% vs 19.7%) and pre-stroke disability (9.6% vs 5.1%), and similar history of stroke, hypertension, diabetes, stroke type and severity of stroke. After age, sex and co-morbidities adjustments, HOS had greater risk of pneumonia: OR (95%CI) = 1.9 (1.3-2.6); malnutrition: OR = 2.2 (1.7-2.9); immediate thrombolysis complications: OR = 5.3 (1.5-18.2); length of stay on HASU > 3 weeks: OR = 2.5 (1.8-3.4); post-stroke disability: OR = 1.8 (1.4-2.4); and in-hospital mortality: OR = 1.8 (1.2-2.4), as well as greater support at discharge including palliative care: OR = 1.9 (1.3-2.8); nursing care: OR = 2.0 (1.3-4.0), help for daily living activities: OR = 1.6 (1.1-2.2); and joint-care planning: OR = 1.5 (1.1-1.9).Conclusions: This detailed analysis of underlying differences in subject characteristics between patients with HOS or COS and adverse consequences provides further insights into understanding poorer outcomes associated with HOS. [ABSTRACT FROM AUTHOR]

The Blue Book published by the British Orthopaedic Association and British Geriatrics Society, together with the introduction of National Hip Fracture Database Audit and Best Practice Tariff, have been influential in improving hip fracture care. We examined ten-year (2009–2019) changes in hip fracture outcomes after establishing an orthogeriatric service based on these initiatives, in 1081 men and 2891 women (mean age = 83.5 ± 9.1 years). Temporal trends in the annual percentage change (APC) of outcomes were identified using the Joinpoint Regression Program v4.7.0.0. The proportions of patients operated beyond 36 h of admission fell sharply during the first two years: APC = − 53.7% (95% CI − 68.3, − 5.2, P = 0.003), followed by a small rise thereafter: APC = 5.8% (95% CI 0.5, 11.3, P = 0.036). Hip surgery increased progressively in patients > 90 years old: APC = 3.3 (95% CI 1.0, 5.8, P = 0.011) and those with American Society of Anaesthesiologists grade ≥ 3: APC = 12.4 (95% CI 8.8, 16.1, P < 0.001). There was a significant decline in pressure ulcers amongst patients < 90 years old: APC = − 17.9 (95% CI − 32.7, 0.0, P = 0.050) and also a significant decline in mortality amongst those > 90 years old: APC = − 7.1 (95% CI − 12.6, − 1.3, P = 0.024). Prolonged length of stay (> 23 days) declined from 2013: APC = − 24.6% (95% CI − 31.2, − 17.4, P < 0.001). New discharge to nursing care declined moderately over 2009–2016 (APC = − 10.6, 95% CI − 17.2, − 2.7, P = 0.017) and sharply thereafter (APC = − 47.5%, 95%CI − 71.7, − 2.7, P = 0.043). The rate of patients returning home was decreasing (APC = − 2.9, 95% CI − 5.1, − 0.7, P = 0.016), whilst new discharge to rehabilitation was increasing (APC = 8.4, 95% CI 4.0, 13.0; P = 0.002). In conclusion, the establishment of an orthogeriatric service was associated with a reduction of elapsed time to hip surgery, a progressive increase in surgery carried out on high-risk adults and a decline in adverse outcomes. [ABSTRACT FROM AUTHOR]

The Nottingham Hip Fracture Score (NHFS) has been developed for predicting 30-day and 1-year mortality after hip fracture. We hypothesise that NHFS may also predict other adverse events. Data from 666 patients (190 men, 476 women), aged 60.2–103.4 years, admitted with a hip fracture to a single centre from 1/10/2015 and 7/12/2017 were analysed. The ability of NHFS to predict mobility within 1 day after surgery, length of stay (LOS) find mortality, and discharge destination was evaluated by receiver operating characteristic curves and two-graph plots. The area under the curve (95% confidence interval [CI]) for predicting mortality was 67.4% (58.4–76.4%), prolonged LOS was 59.0% (54.0–64.0%), discharge to residential/nursing care was 62.3% (54.0–71.5%), and any two of failure to mobilise, prolonged LOS or discharge to residential/nursing care was 64.8% (59.0–70.6%). NHFS thresholds at 4 and 7 corresponding to the lower and upper limits of intermediate range where sensitivity and specificity equal 90% were identified for mortality and prolonged LOS, and 4 and 6 for discharge to residential/nursing care, which were used to create three risk categories. Compared with the low risk group (NHFS = 0–4), the high risk group (NHFS = 7–10 or 6–10) had increased risk of in-patient mortality: rates = 2.0% versus 7.1%, OR (95% CI) = 3.8 (1.5–9.9), failure to mobilise within 1 day of surgery: rates = 18.9% versus 28.3%, OR = 1.7 (1.0–2.8), prolonged LOS (> 17 days): rates = 20.3% versus 33.9%, OR = 2.2 (1.3–3.3), discharge to residential/nursing care: rates = 4.5% vs 12.3%, OR = 3.0 (1.4–6.4), and any two of failure to mobilise, prolonged LOS or discharge to residential/nursing care: rates = 10.5% versus 28.6%, 3.4 (95% CI 1.9–6.0), and stayed 4.1 days (1.5–6.7 days) longer in hospital. High NHFS associates with increased risk of mortality, prolonged LOS and discharge to residential/nursing care, lending further support for its use to identify adverse events. [ABSTRACT FROM AUTHOR]

We examined the distribution of quantitative heel ultrasound (QUS) parameters in population samples of European men and looked at the influence of lifestyle factors on the occurrence of these parameters. Men aged between 40 and 79 years were recruited from eight European centers and invited to attend for an interviewer-assisted questionnaire, assessment of physical performance, and quantitative ultrasound (QUS) of the calcaneus (Hologic; Sahara). The relationships between QUS parameters and lifestyle variables were assessed using linear regression with adjustments for age, center, and weight. Three thousand two hundred fifty-eight men, mean age 60.0 years, were included in the analysis. A higher PASE score (upper vs. lower tertile) was associated with a higher BUA (beta coefficient = 2.44 dB/ Mhz), SOS (beta = 6.83 m/s), and QUI (beta = 3.87). Compared to those who were inactive, those who walked or cycled more than an hour per day had a higher BUA (beta = 3.71 dB/Mhz), SOS (beta = 6.97 m/s), and QUI (beta = 4.50). A longer time to walk 50 ft was linked with a lower BUA (beta = -0.62 dB/ Mhz), SOS (beta = -1.06 m/s), and QUI (beta = -0.69). Smoking was associated with a reduction in BUA, SOS, and QUI. There was a U-shaped association with frequency of alcohol consumption. Modification of lifestyle, including increasing physical activity and stopping smoking, may help optimize bone strength and reduce the risk of fracture in middle-aged and elderly European men. [ABSTRACT FROM AUTHOR]