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Weather and climate patterns play an intrinsic role in societal health, yet a comprehensive synthesis of specific hazard-mortality causes does not currently exist. Country-level health burdens are thus highly uncertain, but harnessing collective expert knowledge can reduce this uncertainty, and help assess diverse mortality causes beyond what is explicitly quantified. Here, surveying 30 experts, we provide the first structured expert judgement of how weather and climate directly impact mortality, using the UK as an example. Current weather-related mortality is dominated by short-term exposure to hot and cold temperatures leading to cardiovascular and respiratory failure. We find additional underappreciated health outcomes, especially related to long-exposure hazards, including heat-related renal disease, cold-related musculoskeletal health, and infectious diseases from compound hazards. We show potential future worsening of cause-specific mortality, including mental health from flooding or heat, and changes in infectious diseases. Ultimately, this work could serve to develop an expert-based understanding of the climate-related health burden in other countries., Competing Interests: Declaration of interests YTEL was funded by a University of Bristol fellowship in Climate and Health. EB was funded by Policy Bristol. CR is funded by a UKRI Future Leaders Fellowship (MR/V021672). NSF received support of H2020 MSCA IF (grant ID 846824). AG was supported by the Medical Research Council-UK (MR/V034162/1). All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The reemergence of the highly pathogenic avian influenza virus (HPAIV) subtype H5N1 in the United Kingdom in 2021-2022 has caused unprecedented epizootic events in wild birds and poultry. During the summer of 2022, there was a shift in virus transmission dynamics resulting in increased HPAIV infection in seabirds, and consequently, a profound impact on seabird populations. To understand the pathological impact of HPAIV in seabirds, we evaluated the virus antigen distribution and associated pathological changes in the tissues of great skua ( Stercorarius skua , n = 8), long-tailed skua ( Stercorarius longicaudus , n = 1), European herring gull ( Larus argentatus , n = 5), and black-headed gull ( Chroicocephalus ridibundus , n = 4), which succumbed to natural infection of HPAIV during the summer of 2022. Cases were collected from Shetland, including Scatness (mainland), No Ness (mainland), Clumlie (mainland), Hermaness (island), Fair Isle (island), Noss (island), and the West Midlands, South East, and South West of England. Grossly, gizzard ulceration was observed in one great skua and pancreatic necrosis was observed in 4 herring gulls, with intralesional viral antigen detected subsequently. Microscopical analysis revealed neuro-, pneumo-, lymphoid-, and cardiomyotropism of HPAIV H5N1, with the most common virus-associated pathological changes being pancreatic and splenic necrosis. Examination of the reproductive tract of the great skua revealed HPAIV-associated oophoritis and salpingitis, and virus replication within the oviductal epithelium. The emergence of HPAIV in seabirds Stercorariidae and Laridae, particularly during summer 2022, has challenged the dogma of HPAIV dynamics, posing a significant threat to wild bird life with potential implications for the reproductive performance of seabirds of conservation importance., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study was concerned with how accurate people are in their knowledge of population norms and statistics concerning such things as the economic, health and religious status of a nation and how those estimates are related to their own demography (e.g age, sex), ideology (political and religious beliefs) and intelligence. Just over 600 adults were asked to make 25 population estimates for Great Britain, including religious (church/mosque attendance) and economic (income, state benefits, car/house ownership) factors as well as estimates like the number of gay people, immigrants, smokers etc. They were reasonably accurate for things like car ownership, criminal record, vegetarianism and voting but seriously overestimated numbers related to minorities such as the prevalence of gay people, muslims and people not born in the UK. Conversely there was a significant underestimation of people receiving state benefits, having a criminal record or a private health insurance. Correlations between select variables and magnitude and absolute accuracy showed religiousness and IQ most significant correlates. Religious people were less, and intelligent people more, accurate in their estimates. A factor analysis of the estimates revealed five interpretable factors. Regressions were calculated onto these factors and showed how these individual differences accounted for as much as 14% of the variance. Implications and limitations are acknowledged., Competing Interests: The authors have declared that no competing interests exist.

This focus article has been prepared by Paul Duff, Paul Holmes, James Aegerter, Cat Man, Ed Fullick, Scott Reid, Fabian Lean, Alex Núñez, Rowena Hansen, Joanna Tye, Lévon Stephan and Ian Brown of the APHA and Caroline Robinson of SRUC., (© 2021 British Veterinary Association.)

Background: Options for patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or catheter ablation remain limited. Stereotactic radiotherapy has been described as a novel treatment option., Methods: Seven patients with recurrent refractory VT, deemed high risk for either first time or redo invasive catheter ablation, were treated across three UK centres with non-invasive cardiac stereotactic ablative radiotherapy (SABR). Prior catheter ablation data and non-invasive mapping were combined with cross-sectional imaging to generate radiotherapy plans with aim to deliver a single 25 Gy treatment. Shared planning and treatment guidelines and prospective peer review were used., Results: Acute suppression of VT was seen in all seven patients. For five patients with at least 6 months follow-up, overall reduction in VT burden was 85%. No high-grade radiotherapy treatment-related side effects were documented. Three deaths (two early, one late) occurred due to heart failure., Conclusions: Cardiac SABR showed reasonable VT suppression in a high-risk population where conventional treatment had failed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To compare global warming potential (GWP) of hospitals converting from single-use sharps containers to reusable sharps containers (SSC, RSC). Does conversion to RSC result in GWP reduction?, Design: Using BS PAS 2050:2011 principles, a retrospective, before/after intervention quantitative model together with a purpose-designed, attributional 'cradle-to-grave' life-cycle tool, were used to determine the annual greenhouse gas (GHG) emissions of the two sharps containment systems. Functional unit was total fill line litres (FLL) of sharps containers needed to dispose of sharps for 1-year period in 40 trusts. Scopes 1, 2 and 3 emissions were included. Results were workload-normalised using National Health Service (NHS) national hospital patient-workload indicators. A sensitivity analysis examined areas of data variability., Setting: Acute care hospital trusts in UK., Participants: 40 NHS hospital Trusts using RSC., Intervention: Conversion from SSC to RSC. SSC and RSC usage details in 17 base line trusts immediately prior to 2018 were applied to the RSC usage details of the 40 trusts using RSC in 2019., Primary Outcome Measure: The comparison of GWP calculated in carbon dioxide equivalents (CO 2 e) generated in the manufacture, transport, service and disposal of 12 months, hospital-wide usage of both containment systems in the 40 trusts., Results: The 40 trusts converting to RSC reduced their combined annual GWP by 3267.4 tonnes CO 2 e (-83.9%); eliminated incineration of 900.8 tonnes of plastic; eliminated disposal/recycling of 132.5 tonnes of cardboard and reduced container exchanges by 61.1%. GHG as kg CO 2 e/1000 FLL were 313.0 and 50.7 for SSC and RSC systems, respectively. A sensitivity analysis showed substantial GHG reductions within unit processes could be achieved, however, their impact on relevant final GWP comparison varied <5% from base comparison., Conclusions: Adopting RSC is an example of a sustainable purchasing decision that can assist trusts meet NHS GHG reduction targets and can reduce GWP permanently with minimal staff behavioural change., Competing Interests: Competing interests: TRG is an international consultant on sharps injury prevention and sharps containment to healthcare facilities, professional associations and contractors in the healthcare sector, and from time to time, Sharpsmart UK (the manufacturer of the RSC studied in this paper) use his services. All other authors are employed by, or associated with, trusts using Sharpsmart reusable sharps containers and declare no conflicts of interest., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The widespread use of drugs in prisons leads to avoidable deaths, poorer health and a poor living environment. The contribution of psychoactive prescription drugs to this problem has received little attention in prison policy or at individual prescriber level., Aims: To determine the extent of unsafe and inappropriate prescribing of psychoactive medications in one UK prison using a newly developed medicines optimisation framework., Method: A medicines optimisation framework was developed based on principles of good prescribing. It was initiated on the opening of a new prison-HMP Berwyn-in February 2017. During the study period, all prisoners at HMP Berwyn were transferred from other prisons. The safety and appropriateness of psychoactive medications were evaluated de novo on reception at HMP Berwyn and during follow up, using the medicines optimisation framework., Results: About 1941 sentenced men arrived at HMP Berwyn between February 2017 and November 2018. Nearly one-third (634, 33%) were on a prescribed psychoactive medication. Seventy-five percent of these (474/634) required a prescription change due to appropriateness or safety concerns. Nearly half (295, 46.5%) received changes at reception despite having already undergone medicines reconciliation at their previous prison. Forty-three percent (275/634) received changes at follow up, most commonly those who had no prior risks identified at reception., Conclusions: Inappropriate and unsafe prescribing of psychoactive medications is occurring in prisons despite mandatory medication reviews. Ongoing monitoring is required to reduce the risk from these medications. A medicines optimisation framework such as this could be adopted across other prisons, worldwide, to help contribute to risk reduction from drug use in prisons. Appropriately modified, a similar framework might help reduce inappropriate and harmful prescribing in hospitals and in the community., (© 2020 John Wiley & Sons Ltd.)

Background: To address the unmet medical need for an effective prophylactic vaccine against Ebola virus we assessed the safety and immunogenicity of three different two-dose heterologous vaccination regimens with a replication-deficient adenovirus type 26 vector-based vaccine (Ad26.ZEBOV), expressing Zaire Ebola virus glycoprotein, and a non-replicating, recombinant, modified vaccinia Ankara (MVA) vector-based vaccine, encoding glycoproteins from Zaire Ebola virus, Sudan virus, and Marburg virus, and nucleoprotein from the Tai Forest virus., Methods: This randomised, observer-blind, placebo-controlled, phase 2 trial was done at seven hospitals in France and two research centres in the UK. Healthy adults (aged 18-65 years) with no history of Ebola vaccination were enrolled into four cohorts. Participants in cohorts I-III were randomly assigned (1:1:1) using computer-generated randomisation codes into three parallel groups (randomisation for cohorts II and III was stratified by country and age), in which participants were to receive an intramuscular injection of Ad26.ZEBOV on day 1, followed by intramuscular injection of MVA-BN-Filo at either 28 days (28-day interval group), 56 days (56-day interval group), or 84 days (84-day interval group) after the first vaccine. Within these three groups, participants in cohort II (14:1) and cohort III (10:3) were further randomly assigned to receive either Ad26.ZEBOV or placebo on day 1, followed by either MVA-BN-Filo or placebo on days 28, 56, or 84. Participants in cohort IV were randomly assigned (5:1) to receive one dose of either Ad26.ZEBOV or placebo on day 1 for vector shedding assessments. For cohorts II and III, study site personnel, sponsor personnel, and participants were masked to vaccine allocation until all participants in these cohorts had completed the post-MVA-BN-Filo vaccination visit at 6 months or had discontinued the trial, whereas cohort I was open-label. For cohort IV, study site personnel and participants were masked to vaccine allocation until all participants in this cohort had completed the post-vaccination visit at 28 days or had discontinued the trial. The primary outcome, analysed in all participants who had received at least one dose of vaccine or placebo (full analysis set), was the safety and tolerability of the three vaccination regimens, as assessed by participant-reported solicited local and systemic adverse events within 7 days of receiving both vaccines, unsolicited adverse events within 42 days of receiving the MVA-BN-Filo vaccine, and serious adverse events over 365 days of follow-up. The secondary outcome was humoral immunogenicity, as measured by the concentration of Ebola virus glycoprotein-binding antibodies at 21 days after receiving the MVA-BN-Filo vaccine. The secondary outcome was assessed in the per-protocol analysis set. This study is registered at ClinicalTrials.gov, NCT02416453, and EudraCT, 2015-000596-27., Findings: Between June 23, 2015, and April 27, 2016, 423 participants were enrolled: 408 in cohorts I-III were randomly assigned to the 28-day interval group (123 to receive Ad26.ZEBOV and MVA-BN-Filo, and 13 to receive placebo), the 56-day interval group (124 to receive Ad26.ZEBOV and MVA-BN-Filo, and 13 to receive placebo), and the 84-day interval group (117 to receive Ad26.ZEBOV and MVA-BN-Filo, and 18 to receive placebo), and 15 participants in cohort IV were assigned to receive Ad26.ZEBOV and MVA-BN-Filo (n=13) or to receive placebo (n=2). 421 (99·5%) participants received at least one dose of vaccine or placebo. The trial was temporarily suspended after two serious neurological adverse events were reported, one of which was considered as possibly related to vaccination, and per-protocol vaccination was disrupted for some participants. Vaccinations were generally well tolerated. Mild or moderate local adverse events (mostly pain) were reported after 206 (62%) of 332 Ad26.ZEBOV vaccinations, 136 (58%) of 236 MVA-BN-Filo vaccinations, and 11 (15%) of 72 placebo injections. Systemic adverse events were reported after 255 (77%) Ad26.ZEBOV vaccinations, 116 (49%) MVA-BN-Filo vaccinations, and 33 (46%) placebo injections, and included mostly mild or moderate fatigue, headache, or myalgia. Unsolicited adverse events occurred after 115 (35%) of 332 Ad26.ZEBOV vaccinations, 81 (34%) of 236 MVA-BN-Filo vaccinations, and 24 (33%) of 72 placebo injections. At 21 days after receiving the MVA-BN-Filo vaccine, geometric mean concentrations of Ebola virus glycoprotein-binding antibodies were 4627 ELISA units (EU)/mL (95% CI 3649-5867) in the 28-day interval group, 10 131 EU/mL (8554-11 999) in the 56-day interval group, and 11 312 mL (9072-14106) in the 84-day interval group, with antibody concentrations persisting at 1149-1205 EU/mL up to day 365., Interpretation: The two-dose heterologous regimen with Ad26.ZEBOV and MVA-BN-Filo was safe, well tolerated, and immunogenic, with humoral and cellular immune responses persisting for 1 year after vaccination. Taken together, these data support the intended prophylactic indication for the vaccine regimen., Funding: Innovative Medicines Initiative and Janssen Vaccines & Prevention BV., Translation: For the French translation of the abstract see Supplementary Materials section., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

This pilot study evaluated a high-energy, high-protein, peptide-based, (medium-chain triglycerides) MCT-containing enteral tube feed (Nutrison Peptisorb Plus HEHP ® , Nutricia Ltd., Trowbridge, BA14 0XQ, UK.) containing 1.5 kcal/mL and 7.5 g protein/100 mL. Fifteen community-based, enterally tube-fed adults (42 (SD 16.3) years) received the intervention feed daily for 28 days, with gastrointestinal tolerance, compliance and nutrient intake assessed at baseline and after the intervention period. Incidence and intensity of constipation ( p = 0.496), nausea ( p = 1.000), abdominal pain ( p = 0.366) and bloating ( p = 0.250) remained statistically unchanged, yet the incidence and intensity of diarrhoea improved significantly after receiving the intervention feed (Z = -2.271, p = 0.023). Compliance with the intervention feed was significantly greater compared to the patient's baseline regimens (99% vs. 87%, p = 0.038). Compared to baseline, use of the intervention feed enabled patients to significantly increase total energy (1676 kcal/day (SD 449) to 1884 kcal/day (SD 537), p = 0.039) and protein intake (73 g/day (SD 17) to 89 g/day (SD 23), p = 0.001), allowing patients to better achieve energy (from 88% to 99%, p = 0.038) and protein (from 101% to 121%, p < 0.001) requirements. This pilot study demonstrates that a high-energy, high-protein, peptide-based, MCT-containing enteral tube feed maintains gastrointestinal tolerance and improves compliance, energy and protein intake in complex, enterally tube-fed, community-based adult patients, though more work is recommended to confirm this.

Background: The epidemiology and risk factors for paediatric urolithiasis (UL) in developed countries are evolving, with increasing rates of metabolic stone-formers. In the United Kingdom (UK), only a single London cohort has been studied in the past three decades. Regional disease patterns across the UK remain unknown. UL has been associated with an increased risk of chronic kidney disease in adults, but long-term paediatric outcomes remain poorly understood., Methods: We assessed the epidemiology of paediatric UL by defining the demographics, incidence, aetiology, recurrence rates and outcomes at tertiary nephro-urology centres in Greater Manchester. Health records of 177 consecutive paediatric urology referrals (0-18 years) for UL between 2002 and 2015 were retrospectively included for observational analysis. Metabolic screening was performed in 105 children., Results: The incidence of paediatric urology referrals for UL was 1.77/100,000 person-years, increasing annually by 13.6%. Mean patient age was 8.2 years and the male:female ratio was 1.3:1. The upper urinary tract was involved in more than 90% of cases and 45% of children presented with multiple calculi. Metabolic abnormalities were identified in 52% of children screened: hypercalciuria (64%), hyperoxaluria (18%) and cystinuria (11%) were the most common. Significant family history was predictive of metabolic abnormalities (OR 4.9:1, 95% CI 1.4-17.0). 30% of children had infective stones, which were more common in children less than 6 years. Ultrasound was found to be 90% sensitive for UL detection. Dimercaptosuccinic acid (DMSA) imaging identified renal scarring in 33 of the 55 children tested (60%). Recurrence was observed in 18% of children over mean 6.4 year follow-up and was more common in metabolic stone-formers. Spontaneous passage was observed in 83% of stones ≤ 5 mm, 69% between 5 and 10 mm and only one calculi > 10 mm., Conclusions: The incidence of paediatric urology referrals for UL is rising in North West England. Metabolic abnormalities were detected in half of the children tested, justifying comprehensive screening. Recurrence is common following paediatric UL, reinforcing the need for stone prevention strategies. The majority of calculi less than 10 mm were found to pass spontaneously with supportive measures, which favours an initial observation period over surgical intervention for small calculi. UL was associated with renal scarring in the analysed population and therefore, children with UL require long-term assessment of blood pressure and proteinuria., (Copyright © 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: It is unknown whether interventions known to improve the healthcare response to domestic violence and abuse (DVA)-a global health concern-are effective outside of a trial., Methods: An observational interrupted time series study in general practice. All registered women aged 16 and above were eligible for inclusion. In four implementation boroughs' general practices, there was face-to-face, practice-based, clinically relevant DVA training, a prompt in the electronic medical record, reminding clinicians to consider DVA, a simple referral pathway to a named advocate, ensuring direct access for women to specialist services, overseen by a national, health-focused DVA organisation, fostering best practice. The fifth comparator borough had only a session delivered by a local DVA specialist agency at community venues conveying information to clinicians. The primary outcome was the daily number of referrals received by DVA workers per 1000 women registered in a general practice, from 205 general practices, in all five northeast London boroughs. The secondary outcome was recorded new DVA cases in the electronic medical record in two boroughs. Data was analysed using an interrupted time series with a mixed effects Poisson regression model., Results: In the 144 general practices in the four implementation boroughs, there was a significant increase in referrals received by DVA workers-global incidence rate ratio of 30.24 (95% CI 20.55 to 44.77, p < 0.001). There was no increase in the 61 general practices in the other comparator borough (incidence rate ratio of 0.95, 95% CI 0.13 to 6.84, p = 0.959). New DVA cases recorded significantly increased with an incident rate ratio of 1.27 (95% CI 1.09 to 1.48, p < 0.002) in the implementation borough but not in the comparator borough (incidence rate ratio of 1.05, 95% CI 0.82 to 1.34, p = 0.699)., Conclusions: Implementing integrated referral routes, training and system-level support, guided by a national health-focused DVA organisation, outside of a trial setting, was effective and sustainable at scale, over four years (2012 to 2017) increasing referrals to DVA workers and new DVA cases recorded in electronic medical records.

On 14 June 2017 at 00:54 h, the worst residential fire since the conclusion of the Second World War broke out in Flat 16, 4th floor of the 24-storey residential Grenfell Tower Block of flats, North Kensington, West London, UK. Seventy-one adults and children died, including one stillbirth. All victims of the Grenfell Tower disaster who died at the scene underwent post-mortem computed tomography (PMCT) imaging using a mortuary-sited mobile computed tomography scanner. For the first time, to the authors' knowledge, the disaster victim identification (DVI) radiology reporting was undertaken remote to the mortuary scanning. Over an 11-week period, 119 scans were undertaken on 16 days, with up to 18 scans a day. These were delivered to a remote reporting centre at Leicester on 13 days with between 2 and 20 scans arriving each day. Using a disaster-specific process pathway, a team of 4 reporters, with 3 support staff members, trialled a prototype INTERPOL DVI radiology reporting form and produced full radiology reports and supporting image datasets such that they were able to provide 96% of prototype DVI forms, 99% of image datasets and 86% of preliminary reports to the DVI teams in London within one working day of image receipt. This paper describes the first use of remote radiology reporting for DVI and exemplifies how remote PMCT reporting can be used to support a DVI process of this scale.

Psychiatric illness and sleeping disorders are important co-morbidities of human immunodeficiency virus (HIV) infection, which impact both the individual and antiretroviral therapy (ART) selection. This systematic review aimed to assess the prevalence of psychiatric illness and sleep disturbance in people living with HIV (PLHIV) in the UK. Systematic searches for publications reporting epidemiological data for psychiatric co-morbidities and sleep disturbance with HIV were conducted in Embase, MEDLINE, Cochrane Library, eight key conferences (2013-2015), and by hand-searching references of included publications. Data were extracted from publications (2000 onwards) reporting the UK prevalence of depression, anxiety, suicide ideation, or sleep disturbance as a co-morbidity of HIV infection. Comparative UK general population data were obtained from the 2007 Adult Psychiatric Morbidity in England household survey, the 2012 Health Survey for England, and 'PatientBase' (epidemiological database). Sixteen publications met the inclusion criteria. Amongst PLHIV in the UK, the prevalence of depression varied from 17-47%, compared with a reported 2-5% prevalence for the UK general population. A similar disparity was observed in the prevalence of anxiety (22-49% PLHIV versus 4-5% general population), depression or anxiety (50-58% PLHIV versus 27% general population), difficulty sleeping (61% PLHIV versus 10% population), and suicide ideation (31% PLHIV versus 1% general population). This systematic review of UK data demonstrates that rates of psychiatric illness and sleep disturbance are substantially higher amongst PLHIV than in the general population. These data underline the importance of fully considering sleep and psychiatric issues prior to selection and prescription of antiretroviral drugs, as well as the need for ongoing psychiatric and psychological support for PLHIV on ART.

Concerns about the relationship between computer games and children's aggression have been expressed for decades, but it is not yet clear whether the content of such games evokes aggression or a prior history of aggression promotes children's interest in aggressive games. Two hundred and sixty-six 7-year-old children from a nationally representative longitudinal sample in the UK played a novel computer game (CAMGAME) in which the child's avatar encountered a series of social challenges that might evoke aggressive, prosocial or neutral behaviour. Aggressive choices during the game were predicted by well-known risk factors for aggressive conduct problems and the children's own early angry aggressiveness as infants. These findings suggest that children who are predisposed to aggression bring those tendencies to virtual as well as real environments., (© 2017 The Authors. Developmental Science Published by John Wiley & Sons Ltd.)

Introduction: This study evaluates a possible change in the demographics and surgical practice observed in a large cohort of patients undergoing total knee replacement (TKR)., Patients and Methods: We performed a retrospective analysis of a prospectively collected data on two groups of consecutive patients undergoing primary TKR. Group one consisted of patients who underwent surgery between 1994 and 1998. Group two consisted of patients who had surgery between 2009 and 2012., Results: The mean age of group two was significantly greater than that of group one: 68.9 years (68.1-69.7 years) for group one versus 70.1 years (69.6-70.6 years) for group two (p = 0.009). The mean BMI of group two was significantly greater than that of group one: 29.5 kg/m 2 (29.0-29.9 kg/m 2 ) for group one versus 32.0 kg/m 2 (31.7-32.3 kg/m 2 ) for group two (p < 0.001). The mean pain component of the AKSS was significantly worse in group one than in group two: 28.6 (27.2-30.0) for group one versus 35.5 (34.6-36.4) for group two (p < 0.001). The mean function component of the AKSS was significantly worse in group one than in group two: 48.6 (47.3-49.9) for group one versus 51.5 (50.7-52.3) for group two (p < 0.001)., Conclusion: This study describes the change in demographics of patients undergoing TKR in our institution over the last two decades.