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Among other tests, Barts Health NHS Trust clinical transplantation laboratory conducts two important gene-detection tests: human leucocyte antigen (HLA)-B*27 (‘B27’, associated with the diagnosis of ankylosing spondylitis) and HLA-B*57:01 (‘B57’, associated with prediction of abacavir hypersensitivity disorder). The turnaround time (TaT) from sample receipt to return of results is important to clinicians and their patients but was not monitored. Furthermore, we anticipated an imminent increase in demand from a forthcoming pathology service merger, together with long-term increases with the rise of personalised genetic medicine.In this quality improvement project, we identified current TaT performance and sources of delay. Over three plan-do-study-act (PDSA) cycles, we tested three change ideas, two involving using IT to remove manual administrative steps and alert us to samples needing progressing; both were retained. The other change involved separating out the targeted tests; we judged this not worthwhile with current demand levels, although something to be re-examined when volumes increase. During the project, we reduced mean TaT from 3.8 to 3.3 days and increased the proportion within our 5-day target from 78% to 100%. These have been sustained (at 3.4 days and 97%) for the 3 months following our PDSA cycles and illustrate that reducing variation can be as impactful as reducing the mean.We conducted this project during the COVID-19 disruption, which reduced demand substantially. We took advantage of this to allow staff to spend time on these improvement activities. Another interesting feature of the work is that during the project, we compared changes in performance on our targeted B27/B57 tests with that on another comparable test as a control, to consider the impact of the general increased attention (the Hawthorne effect). We found that performance on this control also increased comparably, but then fell away after our project finished, while it did not for B27/B57.

Forward-head posture (FHP) is a common postural deviation associated with older age, cervical muscle weakness, poor balance, anteriorly displaced center of mass, increased postural sway and fall risk, impaired cervical proprioception, and possibly vestibular dysfunction. Studies have found increased fall risk in older adults with FHP but have not identified a casual reason for this relationship. This review aims to examine the links between (FHP) and vestibular deficits. While assessment of overall posture, including FHP, is a common component of a physical therapy evaluation, a standardized method of clinical measurement for FHP is lacking. The craniovertebral angle (CVA) appears to be the most reliable method, with FHP defined as less than or equal to 44–53 degrees. Studies where FHP is measured using the CVA appear to be more accurate in identifying associations between this postural deviation and factors that impact postural control in older adults, such as balance and cervical proprioception. Limited studies have found FHP to be associated with duration of clinical symptoms of vestibular disease. FHP also heightens age-related increases in anterior-posterior postural sway. Compelling evidence exists that links FHP with vestibular deficits, increased fall risk, and impaired cervical proprioception. Further research using CVA and a consistent definition of FHP is needed to answer this question and develop clinical practice guidelines.

Purpose Idiopathic intracranial hypertension is a significant cause of preventable blindness. Patients suffer from debilitating headaches, pulsatile tinnitus, nausea, vomiting, photophobia and radicular pain. At this rate, treatment cost will increase to 462.7 million pounds sterling annually by 2030. Weight loss is the only proven disease-modifying therapy for reversal of idiopathic intracranial hypertension. Bariatric surgery leads to superlative weight loss and reversal of related comorbidities. The case series and literature review aim to raise awareness of bariatric surgery as a safe and effective treatment modality for idiopathic intracranial hypertension. Material and Methods The literature review comprises three systematic analysis and one randomised control trial which were identified after a PubMed search. In the case series, we have included four patients with a preoperative diagnosis of long-standing idiopathic intracranial hypertension. They were referred to our department for bariatric surgery by the neuro-ophthalmologist between January and December 2018. They were followed up for 2 years after bariatric surgery. Results All four patients were women with a mean age of 34 years. Mean body mass index reduced from 47.3 kg/m2 before surgery to 30 kg/m2 at the end of 2 years after surgery. They showed significant improvement or resolution in their symptoms related to idiopathic intracranial hypertension, and none of them required further cerebrospinal fluid pressure reducing procedures. Conclusion Bariatric surgery is a safe and effective method of treating idiopathic intracranial hypertension. It is superior compared to medical management and cerebrospinal fluid pressure reducing procedures which have high rates of recurrence.

Purpose: With the increasing burden of chronic pain and opioid use, provider shortages in Eastern Kentucky and West Virginia have experienced many challenges related to chronic pain management. This study tested a practice facilitator model in both academic and community clinics that selected and implemented best practice processes to better assist patients with chronic pain and increase the use of interdisciplinary health care services. Methods: Using a quasi-experimental design, a practice facilitator was assigned to each state’s clinics and trained clinic teams in quality improvement methods to implement chronic pain tool(s) and workflow processes. Charts for 695 patients with chronic pain using opioids, from 8 randomly selected clinics in eastern Appalachia, were reviewed to assess for changes in clinic processes. Results: Statistically significant improvements were found in 10 out of 16 chronic pain best practice process measures. These included improved workflow implementation (P < 0.001), increased urine drug screen test orders (P = 0.001) and increased utilization of controlled medication agreements (P = 0.004). In total, 7 of 8 clinics significantly improved in at least one, if not all, selected and implemented process measures. Conclusions: Our findings indicate that practice facilitation, standardization of workflows and formation of structured clinical teams can improve processes of care in chronic pain management and facilitate the use of interdisciplinary services. Future studies are needed to assess long-term patient-centered outcomes that may result from improved processes of chronic pain care.

Groundwater is the world's largest freshwater resource and due to overextraction, levels have declined in many regions causing extensive social and environmental impacts. Groundwater management seeks to balance and mitigate the detrimental impacts of development, with plans commonly used to outline management pathways. Thus, plan efficiency is crucial, but seldom are plans systematically and quantitatively assessed for effectiveness. This study frames groundwater management as a system control problem in order to develop a novel testability assessment rubric to determine if plans meet the requirements of a control loop, and subsequently, whether they can be quantitatively tested. Seven components of a management plan equivalent to basic components of a control loop were determined, and requirements of each component necessary to enable testability were defined. Each component was weighted based upon proposed relative importance, then segmented into rated categories depending on the degree the requirements were met. Component importance varied but, a defined objective or acceptable impact was necessary for plans to be testable. The rubric was developed within the context of the Australian groundwater management industry, and while use of the rubric is not limited to Australia, it was applied to 15 Australian groundwater management plans and approximately 47% were found to be testable. Considering the importance of effective groundwater management, and the central role of plans, our lack of ability to test many plans is concerning.

Objective Obesity is associated with a high incidence of obstructive sleep apnoea (OSA). Bariatric surgery is postulated to lead to OSA resolution, but there is inconclusive evidence on its efficacy. We used objective measurements to determine the rate of resolution or improvement of OSA in patients who had bariatric procedures in our unit. Results Data was analysed on all patients with OSA who underwent bariatric procedures [laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG)] between June 2012 and September 2016 in our unit. 47 patients (26.7%) were diagnosed with OSA. Mean age was 48.5 years. 63.8% were female. 43 required nocturnal continuous positive airway pressure (CPAP) support. Procedures were LRYGB (n = 26) and LSG (n = 21). Mean excess weight loss was 56.1%. Mean start apnoea-hypopnoea index (AHI) on CPAP was 6.4 events/hr and end AHI was 1.4 events/h. 14 patients (32.6%) had complete OSA resolution and 12 (27.9%) showed improvement in pressure support requirements. We demonstrated that 55.3% of patients had resolution or improvement in OSA following bariatric surgery. However, there was a high rate of non-attendance of follow-up appointments. Future efforts will involve analysis of the reasons for this to ensure more robust monitoring.

ObjectivesThe effective exploitation of what are often called big data is increasingly important. They provide the evidence in evidence-based health care and underpin scientific progress in many domains including social/economic policy. Typically, an optimal analysis involves working directly with microdata; i.e. the detailed data relating to each individual in the dataset. But there are many ethico-legal and other governance restrictions on physically sharing microdata. Furthermore, researchers or institutions may have an extensive intellectual property investment in complex microdata and although keen for other researchers to analyse their data they may not wish to give them a physical copy. These restrictions can discourage the use of optimum approaches to analysing pivotal data and slow scientific progress. Data science groups across the world are exploring privacy-protected approaches to analysing microdata without having to physically share the data. ApproachA two day international workshop was arranged focussing on privacy protected approaches to data analysis – particularly federated analysis where raw data remain at their original site of collection. The workshop considered the range of approaches that exist, and those that are currently being developed. It explored the strengths, weaknesses, opportunities and challenges associated with these methods and identified situations where specific approaches have a particularly important role. The workshop included a number of practical sessions where potential users could watch demonstrations of the various approaches in action and run analyses themselves. ResultsThe Data Analysis with Privacy Protection for Epidemiological Research (DAPPER) workshop was held 22-23rd August 2016, Bristol. We report back to the broader community on the outcomes of this workshop that focussed on exploring current approaches, tools and technical solutions that facilitate sensitive data to be shared and analysed. ConclusionsThe workshop has helped map out key opportunities and challenges and assisted potential users, developers and other stakeholders (e.g. funders/journals) to recognise the strengths and weaknesses of different privacy protected analytic approaches. The workshop will encourage further methodological work in this field and better informed application of existing methods.

Numerical groundwater modelling to support mining decisions is often challenging and time consuming. Simulation of open pit mining for model calibration or prediction requires models that include unsaturated flow, large magnitude hydraulic gradients and often require transient simulations with time varying material properties and boundary conditions. This combination of factors typically results in models with long simulation times and/or some level of numerical instability. In modelling practice, long run times and instability can result in reduced effort for predictive uncertainty analysis, and ultimately decrease the value of the decision-support modelling. This study presents an early application of the Iterative Ensemble Smoother (IES) method of calibration-constrained uncertainty analysis to a mining groundwater flow model. The challenges of mining models and uncertainty quantification were addressed using the IES method and facilitated by highly parallelized cloud computing. The project was an open pit mine in South Australia that required predictions of pit water levels and inflow rates to guide the design of a proposed pumped hydro energy storage system. The IES calibration successfully produced 150 model parameter realizations that acceptably reproduced groundwater observations. The flexibility of the IES method allowed for the inclusion of 1493 adjustable parameters and geostatistical realizations of hydraulic conductivity fields to be included in the analysis. Through the geostatistical realizations and IES analysis, alternative conceptual models of fractured rock aquifer orientation and connections could be conditioned to observation data and used for predictive uncertainty analysis. Importantly, the IES method out-performed finite difference methods when model simulations contained small magnitude numerical instabilities.

This paper documents a dynamic simulation study of inertial response on the U.S. Eastern Interconnection (EI) in the year 2030. The 2030 EI model features 17% wind penetration, which is mainly located in the Midcontinent Independent System Operator (MISO) and the Southwest Power Pool (SPP) territories. This comparison study looks at the difference in system wide inertial responses between wind and conventional generators by displacing the wind machines with synchronous generators. Simulation results show the impact of reduced inertia due to the wind penetration. The performance of wind inertia control is also studied.

Aims: This article presents the results of a survey of clients of Keltoi, a residential rehabilitation facility for former opiate-dependent individuals. The survey was carried out to evaluate the success of its unique programme in assisting participants to pursue a drug-free life.Methods: Between 1- and 3-years post-discharge, 53.7% (n = 80) of all former Keltoi clients (n = 149 at the time of study), were interviewed with respect to abstinence, health, crime and employment measures. This was an uncontrolled cohort study.Findings: Abstinence from all illicit drugs and alcohol in 30 days pre-interview was reported by 51.3% (n = 41) of the cohort; 60.0% (n = 48) reported abstinence from all illicit drugs excluding alcohol. Only 5.4% (n = 5) reported injecting behaviour. Outcomes are presented with respect to crime, health and risk behaviours, social and personal functioning and employment.Conclusions: The percentage of those reporting abstinence from illicit drugs was high at 60.0%, and was associated with ...

Introduction The aim of this study was to determine the diagnostic accuracy of REIMS for dysplasia in human adenomas and early colorectal cancer and to determine changes in mucosal lipid chemistry during cancer initiation. Moreover, we attempted to develop a proof of concept first in man study of a novel REIMS-based endoscope for in-vivo chemical phenotyping of adenomas based on the real time analysis of phosphatidic acid (PA) and phosphatidylethanolamine (PE) metabolism. Experimental procedure A prospective, observational cross-sectional cohort study was performed in patients undergoing elective resection for colorectal cancer or colonoscopy at Imperial College London NHS Trust. Two tissue types were obtained - early colorectal cancer (defined as T1 or T2 according to TNMv6 criteria) and adenomatous polyps. Patients with familial adenomatous polyposis, inflammatory bowel disease or hereditary non-polyposis colon cancer were excluded. Specimens were analyzed ex-vivo using a modified electro-surgical hand piece with the aerosol aspirated into a Xevo G2-S QTof mass spectrometer (Waters Corporation). Multivariate analyses were used to create models which underwent cross-validation using SIMCA (V14, Umetrics, Sweden). Characteristic lipid species were identified using univariate statistics in R Studio (V1.0.44) and Metlin. An endoscopic set up was created using a standard endoscope for proof of concept. Summary of data 19 patients (12:7 F:M) were included with a median age of 74 (range 50-92). Six patients had T1/2 adenocarcinoma and 13 had adenomatous polyps. REIMS was able to accurately distinguish the presence of low grade dysplasia (LGD) vs high grade dysplasia (HGD) in adenomatous polyps (sensitivity 95.0%, specificity 100%). Phosphatidic acids (PA) 38:2 and 38:1 were more abundant in high vs low grade dysplasia (p=0.003). REIMS was also able to identify adenomatous polyps from early cancer (sensitivity 100%, specificity 96.3%). Phosphatidylethanolamine (PE) 36:1, phosphatidic acid (PA) 38:1, glucosylceramide (Glc-Cer) 30:1 and ceramide phosphoethanolamines (PE-Cer) d16:1(4E)/20:0 and d14:1(4E)/22:0 were associated with early cancer formation rather than adenomas (p Conclusion Dysplastic adenomas exhibit mucosal lipid chemistry that is discrete from early colorectal cancer. PA, PE and Glc-Cer have potential use as diagnostic biomarkers. First in man studies of the endoscopic application of REIMS suggest it could serve as a real-time tool for early cancer detection based on in vivo analysis of the mucosal lipidome. Citation Format: Petra Paizs, Eftychios Manoli, Sam E. Mason, James L. Alexander, Zsolt Bodai, Emma White, Afeez Adebesin, Jonathan Hoare, Robert Goldin, Ara W. Darzi, James M. Kinross, Zoltan Takats. Rapid evaporative ionization mass spectrometry (REIMS) analysis of the mucosal lipidome has a high diagnostic accuracy for adenomas and early colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4536.

The UN [United Nations Office on Drugs and Crime (UNODC): World Drug Report, 2005, vol. 1: Analysis. UNODC, 2005.], EU [European Monitoring Centre for Drugs and Drug Addiction (EMCDDA): Annual Report, 2005.http://annualreport.emcdda.eu.int/en/home-en.html.] and WHO [World Health Organisation (WHO): Biregional Strategy for Harm Reduction, 2005-2009. HIV and Injecting Drug Use. WHO, 2005.] have consistently highlighted in recent years the ongoing and persistent nature of opiate and particularly heroin use on a global scale. While this is a global phenomenon, authors have emphasised the significant impact such an epidemic has on individual lives and on society. National prevalence studies have indicated the scale of the problem, but the drug-using career, typically consisting of initiation, habitual use, a treatment-relapse cycle and eventual recovery, is not well understood. This paper presents one of the first ODE models of opiate addiction, based on the principles of mathematical epidemiology. The aim of this model is to identify parameters of interest for further study, with a view to informing and assisting policy-makers in targeting prevention and treatment resources for maximum effectiveness. An epidemic threshold value, R(0), is proposed for the drug-using career. Sensitivity analysis is performed on R(0) and it is then used to examine the stability of the system. A condition under which a backward bifurcation may exist is found, as are conditions that permit the existence of one or more endemic equilibria. A key result arising from this model is that prevention is indeed better than cure.

The rate of cardiovascular diseases (CVD) mortality has decreased over the last few years. However, in rural areas, this reduction is less substantial compared to urban areas despite the effort to ...

The discovery of two genes that predispose individuals to breast cancer has led to great excitement in the scientific world, with enormous interest shown by the media and public. This has often led to misunderstandings about the benefits of these discoveries to individuals with a family history of breast cancer. The pathway to the clinic is often difficult and full of inconsistent explanations. This increases the anxiety experienced by patients and may raise their expectations. It is necessary to be cautious when explaining the application of these discoveries to patients in the clinical setting so that they are offered a balanced view of the realities of detecting faulty genes and of the preventative measures available. Ongoing support and access to health professionals are suggested as vital components of a clinical service, and ongoing evaluation of the advantages and disadvantages of cancer genetic counselling is warrented.

Objective: To compare the incidence and severity of local side effects of urinary-derived gonadotropins administered SC and IM. Design: Prospective randomized study of women undergoing IVF treatment. Setting: Tertiary referral center for assisted reproduction. Patient(s): A total of 71 patients were randomized to receive gonadotropins by the SC (n = 41) or IM (n = 30) route. Intervention(s): One cycle of IVF with gonadotropins administered either SC or IM for ovarian stimulation. Main Outcome Measure(s): Incidence and severity of local side effects, such as redness, itching, swelling, pain, and bruising. Result(s): Pain was the most common side effect, with 55.3% and 70.1% of IM and SC injections, respectively, resulting in pain. There were no statistically significant differences in the incidence of itching or bruising after IM and SC injections. Although there was a higher incidence of redness and swelling in the SC group compared with the IM group, most cases were classified as mild. Conclusion(s): There was a significantly higher incidence of some local side effects after SC gonadotropin administration but most of these were mild and well tolerated by patients.

The migration of doctors and nurses from low- to high-income countries has left many countries relying on mid-level cadres as the mainstay of their health delivery system, Malawi being an example. Although an extremely important resource, little attention has been paid to the management and further development of these cadres. In this paper we use the concept of organisational justice – fairness of treatment, procedures and communication on the part of managers – to explore through a questionnaire how mid-level cadres in jobs traditionally done by higher-level cadres self-assessed their level of job satisfaction. All mid-level health workers present on the day of data collection in 34 health facilities in three health districts of Malawi, one district each from the three geographical regions, were invited to participate; 126 agreed. Perceptions of justice correlated strongly with level of job satisfaction, and in particular perceptions of how well they were treated by their managers and the extent to which they were informed about decisions and changes. Pay was not the only important element in job satisfaction; promotion opportunities and satisfaction with current work assignments were also significant. These findings highlight the important role that managers can play in the motivation, career development and performance of mid-level health workers.

We investigated the visual scanning strategy employed by a group of individuals with a severe traumatic brain injury (TBI) during a facial affect recognition task. Four males with a severe TBI were matched for age and gender with 4 healthy controls. Eye movements were recorded while pictures of static emotional faces were viewed (i.e., sad, happy, angry, disgusted, anxious, surprised). Groups were compared with respect to accuracy in labelling the emotional facial expression, reaction time, number and duration of fixations to internal (i.e., eyes + nose + mouth), and external (i.e., all remaining) regions of the stimulus. TBI participants demonstrated significantly reduced accuracy and increased latency in facial affect recognition. Further, they demonstrated no significant difference in the number or duration of fixations to internal versus external facial regions. Control participants, however, fixated more frequently and for longer periods of time upon internal facial features. Impaired visual scanning can contribute to inaccurate interpretation of facial expression and this can disrupt interpersonal communication. The scanning strategy demonstrated by our TBI group appears more ‘widespread’ than that employed by their normal counterparts. Further work is required to elucidate the nature of the scanning strategy used and its potential variance in TBI.

INTRODUCTION: In April 2004 British General Practitioners started to work under a “new contract”, known as GMS2. This encouraged more formal review of many conditions including asthma. AIMS & OBJECTIVES: The questionnaires would enable us to identify patients willing to have telephone reviews of their asthma, those well controlled, and those with poor control. The questionnaires have allowed us to audit our asthma care over a 10 month period. SUBJECT & METHODS: The patients were identified using our clinical software, and were those who had not attended asthma review in the preceding 12 months. The questionnaires asked about smoking status, telephone reviews, and asthma control. The first cohort was posted in February 2005, and in October 2005 we sent out the same questionnaires to another cohort of “non-attenders”. RESULTS: 199 questionnaires received in February, 120 in October. Overall asthma control was good. From the first set of questionnaires (n= 199, all figure relate to 3 or more times per week), 7.5% were woken; 8.5% had their normal activities disturbed; 28% had their normal asthma symptoms; 22% used their reliever inhaler; 84% were non smokers. October 2005 n= 120, these figures were similar, again all figures relate to >3 times in the previous week; woken at night 7.5%; activities disturbed 10%; asthma symptoms 25%; use of blue inhaler 24%; 80% were non smokers. CONCLUSIONS: The questionnaires provided a snapshot of asthma control in the practice population and were easy and inexpensive to perform. It is rewarding that we have less people who have not had a review, but overall asthma control has not changed. In the future those with poor control should probably be chased more actively, perhaps by their doctor, rather than simply by the administrative staff. Conflict of interest and funding No conflict of interest was declared. Postage for the first (February 2005) questionnaires was kindly supported by AstraZeneca.