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Introduction: Hip fractures are common and cause a huge socioeconomic burden to patients, their carers, and healthcare services worldwide. Our aim was to examine how much hip fracture numbers would be expected to rise over coming decades, simply as a consequence of the ageing of the population., Methods: We used data from the National Hip Fracture Database on the volume of hip fractures occurring in England, Wales and Northern Ireland in the year 2019 (n = 67,210). We projected future numbers of hip fractures by applying this number, assuming stable rates, to population growth forecast data provided by the Office for National Statistics up to the year 2060., Results: By 2060, the number of hip fractures occurring in England, Wales and Northern Ireland are projected to increase by 107 % (n = 139,105). In males, there was an estimated increase of 130 % compared with 97 % in females. There was an estimated increase across all age ranges, however the oldest age groups demonstrated the largest relative increases. The estimated increase for those aged 90 years or over was as high as 348 % and 198 % for males and females, respectively., Conclusion: As a consequence of future ageing of the population, the demand on the health service posed by people with hip fracture is projected to more than double by the year 2060. Policymakers should be striving to mitigate against the huge public health impact of these projections by maximising fracture prevention strategies as far as possible and by improving the quality of hip fracture care., Competing Interests: Declaration of competing interest MW undertakes teaching on basic sciences for Orthopaedic trainees preparing for the FRCS. His institution receives market rate payment for this teaching from Heraeus. He undertakes teaching on total hip replacement for Orthopaedic Consultants and trainees. His institution receives market rate payment for this teaching from DePuy. He is PI on a commercially funded grant (CeramTec) investigating the outcome of ceramic bearings in total hip replacement. He is PI of the National Joint Registry lot 2 contract (statistical analysis) team. GM has received personal fees for undertaking medicolegal work for Leigh Day. AJu has received consultancy fees from Freshfields Bruckhaus Deringer and has held advisory board positions (which involved receipt of fees) from Anthera Pharmaceuticals, INC. TM, DC, SH, AJo have no conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Veterans residing in Northern Ireland (NI) likely experience higher levels of co-occurring lifetime trauma exposure and associated co-occurring mental health symptoms, due to the Troubles. As NI veterans have been subject to little exploration it is difficult to know how to support them. This exploratory study explored the co-occurrence of mental health symptoms as a function of co-occurring traumatic experiences., Methods: Two latent class analyses (LCA) were conducted on NI veteran data (n = 609). One LCA factored endorsements of 16-lifetime traumatic events, with a separate LCA exploring the co-occurrence of symptoms across six mental health domains. Mental health symptom classes were considered as a function of trauma classes, military-specific variables, gender and age., Results: Three trauma classes were identified: High Multi Trauma (10.84%); High Combat/Conflict (47.62%); Moderate Combat Conflict (41.54%), and three mental health symptom classes: High Co-occurring Mental Health (19.38%); High Depression Moderate Anxiety/Alcohol (24.63%); Moderate Alcohol/Normative (55.99%). Significant predictors of High Co-occurring Mental Health class membership were UDR service, 'Worst' military trauma and High Multi Trauma class membership. Both combat classes had a negative relationship with the High Co-occurring Mental Health. Predictors of the High Depression Moderate Anxiety/Alcohol class were High Multi Trauma class membership and UDR service, with Age and Moderate Combat Class membership having a negative relationship., Discussion: NI veterans could be labelled as 'traumatised' due to high levels of combat/conflict exposure, yet the two combat classes seemed unrelated to membership of poorer mental health classes. UDR membership indicated that living in one's theatre of war could have mental health implications. It was concerning that 45% experienced some co-occurring mental health symptoms with 19% experiencing the poorest symptoms. Hazardous alcohol use appeared unrelated to poor mental health. Further research is needed, utilising robust methods. No clinical inferences are to be made from this exploratory study., (© 2024. The Author(s).)

There are growing concerns about the impact of pollution on maternal and infant health. Despite an extensive correlational literature, observational studies which adopt methods that seek to address potential biases due to unmeasured confounders draw mixed conclusions. Using a population database of births in Northern Ireland (NI) linked to localized geographic information on pollution in mothers' postcodes (zipcodes) of residence during pregnancy, we examine whether prenatal exposure to PM 2.5 is associated with a comprehensive range of birth outcomes, including placental health. Overall, we find little evidence that particulate matter is related to infant outcomes at the pollution levels experienced in NI, once we implement a mother fixed effects approach that accounts for time-invariant factors. This contrasts with strong associations in models that adjust for observed confounders but without fixed effects. While reducing ambient air pollution remains an urgent public health priority globally, our results imply that further improvements in short-run levels of prenatal PM 2.5 exposure in a relatively low-pollution, higher-income country context, are unlikely to impact on birth outcomes at the population level., (© 2024 The Author(s). Health Economics published by John Wiley & Sons Ltd.)

Aims: The COVID-19 pandemic has disrupted the provision of arthroplasty services in England, Wales, and Northern Ireland. This study aimed to quantify the backlog, analyze national trends, and predict time to recovery., Methods: We performed an analysis of the mandatory prospective national registry of all independent and publicly funded hip, knee, shoulder, elbow, and ankle replacements in England, Wales, and Northern Ireland between January 2019 and December 2022 inclusive, totalling 729,642 operations. The deficit was calculated per year compared to a continuation of 2019 volume. Total deficit of cases between 2020 to 2022 was expressed as a percentage of 2019 volume. Sub-analyses were performed based on procedure type, country, and unit sector., Results: Between January 2020 and December 2022, there was a deficit of 158,994 joint replacements. This is equivalent to over two-thirds of a year of normal expected operating activity (71.6%). There were 104,724 (-47.1%) fewer performed in 2020, 41,928 (-18.9%) fewer performed in 2021, and 12,342 (-5.6%) fewer performed in 2022, respectively, than in 2019. Independent-sector procedures increased to make it the predominant arthroplasty provider (53% in 2022). NHS activity was 73.2% of 2019 levels, while independent activity increased to 126.8%. Wales (-136.3%) and Northern Ireland (-121.3%) recorded deficits of more than a year's worth of procedures, substantially more than England (-66.7%). It would take until 2031 to eliminate this deficit with an immediate expansion of capacity over 2019 levels by 10%., Conclusion: The arthroplasty deficit following the COVID-19 pandemic is now equivalent to over two-thirds of a year of normal operating activity, and continues to increase. Patients awaiting different types of arthroplasty, in each country, have been affected disproportionately. A rapid and significant expansion in services is required to address the deficit, and will still take many years to rectify., Competing Interests: J. M. R. French reports a two-year clinical research fellowship funded by Orthopaedic Research UK and the British Hip Society, related to this study. K. Deere and A. Sayers report grants or contracts from Healthcare Quality Improvement Partnership: National Joint Registry, unrelated to this study. T. Jones reports a grant from the National Joint Registry, related to this study. D. J. Pegg is member of the National Joint Registry (NJR) executive committee and chairs the NJR data quality committee. M. R. Reed reports grants or contracts from Stryker, Zimmer Biomet, Heraeus, Link, Depuy, Smith & Nephew, Implantcast, Biocomposites, and Microsoft, consulting fees from Heraeus and Pharmacosmos, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Zimmer Biomet, Heraeus, Stryker, Pharmacosmos, Ethicon, and Amotio, and stock or stock options in openpredictor Holdings and OPCI, and is an executive of the National Joint Registry, all of which are unrelated to this study. M. R. Whitehouse is the chief investigator for the lot 2 contract for the National Joint Registry: Statistical Support, Analysis and Associated Services, and reports royalties or licenses from Taylor & Francis, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Heraeus, and is a member of the editorial board of The Bone & Joint Journal and a member of the research committee for the British Orthopaedic Association and the British Hip Society., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Background: Periprosthetic fractures are rare but serious complications of unicompartmental knee arthroplasty (UKA). Although cementless UKA has a lower risk of loosening than cemented, there are concerns that tibial fracture risk may be higher given the reliance on interference fit for primary stability. The risk of fracture and the effect of surgical fixation are currently unknown. We compared the periprosthetic fracture rate following cemented and cementless UKA surgery., Methods: A total of 14,122 medial mobile-bearing UKAs (7,061 cemented and 7,061 cementless) from the National Joint Registry and Hospital Episodes Statistics database were propensity score-matched. Cumulative fracture rates were calculated and Cox regressions were used to compare fixation groups., Results: The three-month periprosthetic fracture rates were similar (P = .80), being 0.10% in the cemented group and 0.11% in the cementless group. The fracture rates were highest during the first three months postoperatively, but then decreased and remained constant between one and 10 years after surgery. The one-year cumulative fracture rates were 0.2% (confidence interval [CI]: 0.1 to 0.3) for cemented and 0.2% (CI: 0.1 to 0.3) for cementless cases. The 10-year cumulative fracture rates were 0.8% (CI: 0.2 to 1.3) and 0.8% (CI: 0.3 to 1.3), respectively. The hazard ratio during the whole study period was 1.06 (CI: 0.64 to 1.77; P = .79)., Conclusions: The periprosthetic fracture rate following mobile bearing UKA surgery is low, being about 1% at 10 years. There were no significant differences in fracture rates between cemented and cementless implants after matching. We surmise that surgeons are aware of the higher theoretical risk of early fracture with cementless components and take care with tibial preparation., Levels of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to examine whether an aggregate of health risk behaviours is associated with the number of untreated dental caries among 12- and 15-year-old children in England, Wales and Northern Ireland., Materials and Methods: Data were from the Children's Dental Health Survey (CDHS) 2013, a nationally representative sample of England, Wales and Northern Ireland. The survey included assessment of oral health and data on socioeconomic, demographic and behavioural factors pertaining to children aged 12-15 years. Tooth condition (decayed, missing and filled) was assessed by NHS dentists. The survey included questions on age, sex, country, index of multiple deprivation, smoking, alcohol consumption, frequent sugar consumption and sweetened sodas, infrequent dental visit, infrequent toothbrushing and infrequent consumption of fresh fruits. Health risk behaviours were summed up to create an aggregate variable of health risk behaviour. The association between number of untreated caries and the aggregate of health risk behaviours was assessed using negative binomial regression and adjusting for age, sex, country and deprivation., Results: The total number of children included in the analysis was 4414. The mean number of untreated caries was generally higher among children with health risk behaviours. The aggregate of risk behaviour was associated with greater prevalence of untreated dental caries with rate ratio (RR) 1.26 (95% confidence interval: 1.18, 1.36)., Conclusion: This study demonstrated an association between an aggregate of health risk behaviours and untreated caries. The findings highlight the importance of addressing multiple risk factors not only those directly related to dental caries., (© 2022 The Authors. International Journal of Dental Hygiene published by John Wiley & Sons Ltd.)

Background: Aimed to compare the prevalence, characteristics, and associated mortality risk of frailty in Northern Ireland (NI) and the Republic of Ireland (ROI)., Methods: Secondary analysis of the first wave of two nationally representative cohorts, the Northern Ireland Cohort for the Longitudinal Study of Ageing or NICOLA study (N = 8504) and the Irish Longitudinal Study on Ageing or TILDA study (N = 8504). Frailty was assessed using a harmonized accumulation deficits frailty index (FI) containing 30 items. FI scores classified individuals as non-frail (<0.10), pre-frail (0.10-0.24) and frail (≥0.25). Linkage to respective administrative data sources provided mortality information with a follow-up time of 8 years., Results: The prevalence of frailty was considerably higher in NI compared with the ROI (29.0% compared with 15.0%), though pre-frailty was slightly lower (35.8% and 37.3%, respectively). Age, female sex, and lower socio-economic status were consistently associated with a higher likelihood of both pre-frailty and frailty. In the pooled analysis, both frailty and pre-frailty were higher in NI (RR = 2.68, 95% CIs 2.45, 2.94 and RR = 1.30, 95% CIs 1.21, 1.40, respectively). Frailty was associated with an increased mortality risk in both cohorts, even after full adjustment for all other characteristics, being marginally higher in TILDA than in NICOLA (HR = 2.43, 95% CIs 2.03, 2.91 vs. HR = 2.31, 95% CIs 1.90, 2.79)., Conclusions: Frailty is a major public health concern for both jurisdictions. Further research and monitoring are required to elucidate why there is a higher prevalence in NI and to identify factors in early life that may be driving these differences., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Public Health Association.)

Cushing's disease is a rare condition that occurs due to an adrenocorticotrophin-producing corticotrophinoma arising from the pituitary gland. The consequent hypercortisolaemia results in multisystem morbidity and mortality. This study aims to report incidence, clinicopathological characteristics, remission outcomes and mortality in a regional pituitary neurosurgical cohort of patients diagnosed with Cushing's disease in Northern Ireland (NI) from 2000 to 2019. Clinical, biochemical and radiological data from a cohort of patients operated for Cushing's disease were retrospectively collected and analysed. Fifty-three patients were identified, resulting in an estimated annual incidence of Cushing's disease of 1.39-1.57 per million population per year. Females accounted for 72% (38/53) of the cohort. The majority (74%, 39/53) of corticotrophinomas were microadenomas and in 44% (17/39) of these no tumour was identified on preoperative magnetic resonance imaging. Histopathological characterisation was similarly difficult, with no tumour being identified in the histopathological specimen in 40% (21/53) of cases. Immediate postoperative remission rates were 53% and 66% when considering serum morning cortisol cut-offs of ≤ 50 nmol/L (1.8 µg/dL) and ≤ 138 nmol/L (5 µg/dL), respectively, in the week following pituitary surgery. Approximately 70% (37/53) of patients achieved longer-term remission with a single pituitary surgery. Three patients had recurrent disease. Patients with Cushing's disease had a significantly higher mortality rate compared to the NI general population (standardised mortality ratio 8.10, 95% CI 3.3-16.7, P < 0.001). Annual incidence of Cushing's disease in NI is consistent with other Northern European cohorts. Functioning corticotrophinomas are a clinically, radiologically and histopathologically elusive disease with increased mortality compared to the general population.

Background: Patients presenting to Emergency Department (ED) with self-harm are recognized to be at high risk of suicide and other causes of death in the immediate period following ED presentation. It is also recognized that there is a large variation in the management and care pathways that these patients experience at EDs., Aims: This study asks if there is a significant variation in mortality risk according to hospital attended and if this is explained by differences in care management., Methods: Population-wide data from the Northern Ireland Registry of Self-Harm from April 2012 were linked with centrally held mortality records to December 2019, providing data on self-harm type and ED care. Cox proportional hazards models analyzed mortality risk, coded as suicide, all-external causes and all-cause mortality., Results: Analysis of the 64,350 ED presentations for self-harm by 30,011 individuals confirmed a marked variation across EDs in proportion of patients receiving mental health assessment and likelihood of admission to general and psychiatric wards. There was a significant variation in suicide risk following attendance according to ED attended with the three-fold range between the lowest (HR adj 0.32 95% CIs 0.16, 0.67) and highest. These differences persisted even after adjustment for patient characteristics, variation in types of self-harm, and care management at the ED., Conclusions: This study suggests that while the management of self-harm cases in the ED is important, it is the availability and access to, and level of engagement with, the subsequent management and care in the community rather than the immediate care at EDs that is most critical for patients presenting to ED with self-harm. However, the initial care in ED is an important gateway in initiating referrals to these services., (© 2023. The Author(s).)

Introduction: Endometriosis affects 10% of women of reproductive age. There is evidence for a left lateral predisposition of endometriotic lesions and a 1.9-fold greater risk of ovarian cancer in endometriosis. The aim of this study is to determine whether a left lateral predisposition of ovarian clear-cell carcinoma (CCC) and endometrioid carcinoma (EC) exists., Materials and Methods: A retrospective cohort study of all EC and CCC patients in Northern Ireland between March-2011 and June-2018. ANOVA was used to analyse preoperative prediction of stage, chi-squared (χ2) was used to compare left- and right-sided masses. Survival was estimated using Kaplan-Meier and log-rank test. A p-value <0.05 was considered significant., Results: 158 patients were identified (95 EC, 55 CCC, 8 mixed). Mean age was 57.65 years with 69% presenting at stage 1. The mean CA125 was 559 U/mL (p = 0.850) and mean abdominal mass size was 14.12 cm (p = 0.732). The most common presenting symptom was an abdominal mass (37%). Despite 67% of patients having endometriosis on final pathology, only 8.9% had a known history pre-operatively. 51% of tumours were located on the left (p = 0.036). For unilateral tumours this was significant for EC (P = 0.002) but not for CCC (P = 0.555). The 1-, 3- and 5-year overall survival for all types/stages was 85%, 78% and 71% respectively., Conclusion: While CCC and EC are associated with endometriosis, only EC exhibits a left lateral predisposition. There is no association between preoperative CA125 or abdominal mass size and stage of disease., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier Ltd.)

Background: Bovine viral diarrhoea (BVD) is caused by Pestivirus A and Pestivirus B. Northern Ireland (NI) embarked on a compulsory BVD eradication scheme in 2016, which continues to this day, so an understanding of the composition of the pestivirus genotypes in the cattle population of NI is required., Methods: This molecular epidemiology study employed 5' untranslated region (5'UTR) genetic sequencing to examine the pestivirus genotypes circulating in samples taken from a hotspot of BVD outbreaks in the Enniskillen area in 2019., Results: Bovine viral diarrhoea virus (BVDV)-1e (Pestivirus A) was detected for the first time in Northern Ireland, and at a high frequency, in an infection hotspot in Enniskillen in 2019. There was no evidence of infection with BVDV-2 (Pestivirus B), Border disease virus (pestivirus D) or HoBi-like virus/BVDV-3 (pestivirus H)., Limitations: Only 5'UTR sequencing was used, so supplementary sequencing, along with phylogenetic trees that include all BVDV-1 genotype reference strains, would improve accuracy. Examination of farm locations and animal movement/trade is also required., Conclusions: Genotype BVDV-1e was found for the first time in Northern Ireland, indicating an increase in the genetic diversity of BVDV-1, which could have implications for vaccine design and highlights the need for continued pestivirus genotypic surveillance., (© 2024 Agri‐Food and Biosciences Institute. Veterinary Record published by John Wiley & Sons Ltd. on behalf of British Veterinary Association.)

The COVID-19 pandemic caused far-reaching societal changes, including significant educational impacts affecting over 1.6 billion pupils and 100 million education practitioners globally. Senior school leaders were at the forefront and were exposed to particularly high demands during a period of "crisis leadership". This occupation were already reporting high work-related stress and large numbers leaving the profession preceding COVID-19. This cross-sectional descriptive study through the international COVID-Health Literacy network aimed to examine the well-being and work-related stress of senior school leaders (n = 323) in Wales (n = 172) and Northern Ireland (n = 151) during COVID-19 (2021-2022). Findings suggest that senior school leaders reported high workloads (54.22±11.30 hours/week), low well-being (65.2% n = 202, mean WHO-5 40.85±21.57), depressive symptoms (WHO-5 34.8% n = 108) and high work-related stress (PSS-10: 29.91±4.92). High exhaustion (BAT: high/very high 89.0% n = 285) and specific psychosomatic complaints (experiencing muscle pain 48.2% n = 151) were also reported, and females had statistically higher outcomes in these areas. School leaders were engaging in self-endangering working behaviours; 74.7% (n = 239) gave up leisure activities in favour of work and 63.4% (n = 202) sacrificed sufficient sleep, which was statistically higher for females. These findings are concerning given that the UK is currently experiencing a "crisis" in educational leadership against a backdrop of pandemic-related pressures. Senior leaders' high attrition rates further exacerbate this, proving costly to educational systems and placing additional financial and other pressures on educational settings and policy response. This has implications for senior leaders and pupil-level outcomes including health, well-being and educational attainment, requiring urgent tailored and targeted support from the education and health sectors. This is particularly pertinent for Wales and Northern Ireland as devolved nations in the UK, who are both implementing or contemplating major education system level reforms, including new statutory national curricula, requiring significant leadership, engagement and ownership from the education profession., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Marchant et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Lung cancer is a major cause of death in Western countries, but survival had never been studied in Northern Ireland (NI) on a population basis prior to this study., Aims: The primary aims were to describe the survival of patients with primary lung cancer, evaluate the effect of treatment, identify patient characteristics influencing survival and treatment and describe current trends in survival., Methods: A population-based study identified all incident cases of primary lung cancer in NI during 1991-2 and followed them for 21 months. Their clinical notes were traced and relevant details abstracted. Survival status was monitored via the Registrar General's Office, and ascertainment is thought to be near-complete. Appropriate statistical methods were used to analyse the survival data., Results: Some 855 incident cases were studied. Their 1-year survival was 24.5% with a median survival time of 4.7 months. Surgical patients had the best 1-year survival, 76.8%; however, adjustment suggested that about half of the benefit could be attributed to case-mix factors. Factors influencing treatment allocation were also identified, and a screening test showed the discordance between 'model' and 'medic': 210 patients were misclassified. Finally, the current trend in 1-year survival observed in the Republic of Ireland was best in the British Isles., Conclusions: Overall, survival remains poor. The better survival of surgical patients is due, in part, to their superior case-mix profiles. Survival with other therapies is less good suggesting that the criteria for treatment might be relaxed with advantage using a treatment model to aid decision-making., (© 2023. The Author(s).)

Background: Skin cancer is a prevalent cancer in the UK. Its rising incidence and mortality rates are expected to result in substantial financial implications, particularly on diagnostic and treatment services for skin cancer management in Northern Ireland (NI). Such anticipated disease increases underscore the need for prevention and control measures that should help guide policymaking and planning efforts., Methods: We conducted a cost of illness study to assess the economic impact of skin cancer in NI from the healthcare system's perspective, using a bottom-up method, employing NHS reference costs (UK£) for skin cancer diagnosis and treatment patient pathways in 2021/22. Sensitivity analyses varied diagnostic volumes by applying multipliers for benign cases, assuming a diagnostic conversion rate of 6.8%, and examined an alternative chemotherapy regimen compliance rate of 75%. Additionally, proportional cost increases were projected based on future estimated increases of 9% and 28% to malignant melanoma (MM) cases for diagnostic, treatment, and follow-up volumes., Results: Significant numbers of non-melanoma skin cancers (NMSC) and MM cases were recorded, 4289 NMSCs and 439 MM cases. The total cost for managing NMSC was £ 3,365,350. Total costs for MM skin cancer were £ 13,740,681, including £ 8,753,494 for procurement, administration, and chemotherapy drug use. Overall healthcare spending on skin cancer care totalled £ 21,167,651. Sensitivity analysis suggested diagnostic cost may increase significantly to £ 12,374,478 based on referral volume assumptions. If base case rates rise by 9 or 28% estimated total costs of treating skin cancer will increase to £ 22.3 million and £ 24.9 million, respectively., Conclusions: Skin cancer management costs in NI totalled ∼£ 21.1 million to £ 32.1 million, depending on diagnostic referral assumptions. Costs have risen ∼10-fold over the past decade for MM due largely to chemotherapy costs. A predicted 28% increase in MM cases by 2040 would lead to ∼£ 3.8 million of additional expenditures, providing a significant challenge for cancer health systems., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Undervaccination (receiving fewer than the recommended number of SARS-CoV-2 vaccine doses) could be associated with increased risk of severe COVID-19 outcomes-ie, COVID-19 hospitalisation or death-compared with full vaccination (receiving the recommended number of SARS-CoV-2 vaccine doses). We sought to determine the factors associated with undervaccination, and to investigate the risk of severe COVID-19 outcomes in people who were undervaccinated in each UK nation and across the UK., Methods: We used anonymised, harmonised electronic health record data with whole population coverage to carry out cohort studies in England, Northern Ireland, Scotland, and Wales. Participants were required to be at least 5 years of age to be included in the cohorts. We estimated adjusted odds ratios for undervaccination as of June 1, 2022. We also estimated adjusted hazard ratios (aHRs) for severe COVID-19 outcomes during the period June 1 to Sept 30, 2022, with undervaccination as a time-dependent exposure. We combined results from nation-specific analyses in a UK-wide fixed-effect meta-analysis. We estimated the reduction in severe COVID-19 outcomes associated with a counterfactual scenario in which everyone in the UK was fully vaccinated on June 1, 2022., Findings: The numbers of people undervaccinated on June 1, 2022 were 26 985 570 (45·8%) of 58 967 360 in England, 938 420 (49·8%) of 1 885 670 in Northern Ireland, 1 709 786 (34·2%) of 4 992 498 in Scotland, and 773 850 (32·8%) of 2 358 740 in Wales. People who were younger, from more deprived backgrounds, of non-White ethnicity, or had a lower number of comorbidities were less likely to be fully vaccinated. There was a total of 40 393 severe COVID-19 outcomes in the cohorts, with 14 156 of these in undervaccinated participants. We estimated the reduction in severe COVID-19 outcomes in the UK over 4 months of follow-up associated with a counterfactual scenario in which everyone was fully vaccinated on June 1, 2022 as 210 (95% CI 94-326) in the 5-15 years age group, 1544 (1399-1689) in those aged 16-74 years, and 5426 (5340-5512) in those aged 75 years or older. aHRs for severe COVID-19 outcomes in the meta-analysis for the age group of 75 years or older were 2·70 (2·61-2·78) for one dose fewer than recommended, 3·13 (2·93-3·34) for two fewer, 3·61 (3·13-4·17) for three fewer, and 3·08 (2·89-3·29) for four fewer., Interpretation: Rates of undervaccination against COVID-19 ranged from 32·8% to 49·8% across the four UK nations in summer, 2022. Undervaccination was associated with an elevated risk of severe COVID-19 outcomes., Funding: UK Research and Innovation National Core Studies: Data and Connectivity., (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.)

Males accounted for half the United Kingdom population in 2021 yet they fail to be prioritised in health and social policies. As examining the health of males and females collectively falls short in accounting for the complexities associated with gendered health outcomes, male health should be considered as a separate policy issue. The island of Ireland has two jurisdictions, the Republic of Ireland and Northern Ireland (NI); however, only the former has implemented a men's health policy. As well as a policy vacuum within NI, few studies have comprehensively examined male health. To address this shortcoming, a narrative review of males' physical and mental health trends in NI is presented to determine the need for a men's health policy. A collation of secondary administrative data and survey data was conducted. The narrative review highlights the importance of utilising a holistic framework to understand men's health. Key findings include high male suicide rates and young males being more likely to report certain mental health problems. The study concludes that a male health policy is needed. To achieve this, a Health Impact Pyramid was developed, and it illustrates practical steps that can be taken to support decision-makers, service providers and individual males., (© 2023 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for the Sociology of Health & Illness.)

Introduction: The Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA) study is the largest study of ageing in Northern Ireland (NI). The Harmonised Cognitive Assessment Protocol (HCAP) is a substudy of NICOLA designed to assess cognitive impairment and dementia in individuals aged 65 and over. The NICOLA-HCAP substudy is funded by the National Institute on Aging as part of a network for enhancing cross-national research within a worldwide group of population-based, longitudinal studies of ageing, all of which are centred around the US-based Health and Retirement Study., Methods and Analysis: The NICOLA-HCAP study will draw on the main NICOLA cohort (of 8283 participants) and randomly sample 1000 participants aged 65 and over to take part in the substudy. Participants will complete a series of cognitive tests (n=19) via a computer-assisted personal interview administered in their home (or alternatively within the research centre) and will be asked to nominate a family member or friend to complete an additional interview of validated instruments to provide information on respondent's prior and current cognitive and physical functioning and whether the individual requires help with daily activities. The objectives of the study are: to investigate the prevalence of dementia and cognitive impairment in NICOLA; harmonise scoring of the NICOLA-HCAP data to the HCAP studies conducted in Ireland, the USA and England; to explore the validity of dementia estimates; and investigate the risk factors for dementia and cognitive impairment., Ethics and Dissemination: The study received ethical approval from the Faculty of Medicine, Health and Life Sciences Research Ethics Committee, Queen's University Belfast. We will provide data from the Northern Irish HCAP to the research community via data repositories such as the Dementias Platform UK and Gateway to Global Aging to complement existing public data resources and support epidemiological research by others. Findings will also be disseminated through peer-reviewed publications and at international conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Unicompartmental knee replacement (UKR) is an effective surgical strategy in patients with isolated medial or lateral compartment osteoarthritis. Study aims were to (1) describe the epidemiology of patients undergoing revision of UKR to a hinge knee replacement (HKR); (2) identify factors influencing time to revision; (3) evaluate HKR survival., Materials and Methods: An analysis of National Joint Registry data was undertaken, exploring revision of UKR to HKR between 2007 and April 2021. Descriptive analysis of eligible patients and Cox Regression to identify key determinants of time to revision were performed. Failure of HKR post-revision was assessed using survival analysis., Results: 111 patients underwent revision of UKR to HKR. Median age at revision was 70 years and most common indications were instability (n = 42) and infection (n = 22). The most common implant was a rotating HKR. Significant independent factors associated with earlier revision were periprosthetic fracture (p = 0.03) and malalignment (p = 0.03). Progressive osteoarthritis (p = 0.01) and higher ASA grades (3: p = 0.01, 4: p < 0.01) delayed time to revision; patient sex and age were not significant factors. Ten patients required subsequent re-revision; median age at re-revision was 61 years. HKR revised from UKR had an 89.3% revision-free risk at 5 years. Male sex (p < 0.01) and younger age (p < 0.01) were associated with re-revision., Conclusions: Factors associated with time to revision may be used to counsel patients prior to UKR. The survivorship of the HKR of 89.3% at 5 years is concerning and careful consideration should be given when using this level of constraint when revising UKR in younger or male patients., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Since the start of the Covid-19 pandemic primary and secondary health care services in Northern Ireland have observed an increase in the number of patients who have had bariatric surgery outside of the UK. This study sought to estimate the frequency of bariatric surgery tourism and to audit indications, blood monitoring and medical complications., Methods: All primary care centres within the Western Health Social Care Trust (WHSCT) were invited to document the number of patients undergoing bariatric surgery between January 1, 2017 and December 31, 2022. For one primary care centre, patients who underwent bariatric surgery were assessed against the National Institute of Health and Clinical Excellence (NICE) guideline indications for bariatric surgery. In addition, the blood monitoring of these patients was audited against the British Obesity and Metabolic Surgery Society (BOMSS) guidelines for up to two years following surgery. Medical contacts for surgical complications of bariatric surgery were recorded., Results: Thirty-five of 47 (74.5%) GP surgeries replied to the survey, representing 239,961 patients among 325,126 registrations (73.8%). In the six year study period 463 patients had reported having bariatric surgery to their GP. Women were more likely to have had bariatric surgery than men (85.1% versus 14.9%). There was a marked increase in the number of patients undergoing bariatric surgery with each year of the study (p<0.0001 chi square for trend). Twenty-one of 47 patients (44.7%) evaluated in one primary care centre fulfilled NICE criteria for bariatric surgery. The level of three-month monitoring ranged from 23% (for vitamin D) to 89% (electrolytes), but decreased at two years to 9% (vitamin D) and 64% (electrolytes and liver function tests). Surgical complication prevalence from wound infections was 19% (9 of 44). Antidepressant medications were prescribed for 23 of 47 patients (48.9%)., Conclusions: The WHSCT has experienced a growing population of patients availing of bariatric surgery outside of the National Health Service. In view of this and the projected increase in obesity prevalence, a specialist obesity management service is urgently required in Northern Ireland., (Copyright © 2024 Ulster Medical Society.)

Background: Whether increased BMI is associated with an increased risk of venous thromboembolism (VTE) is controversial. Despite this, BMI > 40 kg/m 2 remains a common cutoff for lower limb arthroplasty eligibility. Current United Kingdom national guidelines list obesity as a risk factor for VTE, but these are based on evidence that has largely failed to differentiate between potentially minor (distal deep vein thrombosis [DVT]), and more harmful (pulmonary embolism [PE] and proximal DVT) diagnoses. Determining the association between BMI and the risk of clinically important VTE is needed to improve the utility of national risk stratification tools., Questions/purposes: (1) In patients undergoing lower limb arthroplasty, is BMI 40 kg/m 2 or higher (morbid obesity) associated with an increased risk of PE or proximal DVT within 90 days of surgery, compared with patients with BMI less than 40 kg/m 2 ? (2) What proportion of investigations ordered for PE and proximal DVT were positive in patients with morbid obesity who underwent lower limb arthroplasty compared with those with BMI less than 40 kg/m 2 ?, Methods: Data were collected retrospectively from the Northern Ireland Electronic Care Record, a national database recording patient demographics, diagnoses, encounters, and clinical correspondence. Between January 2016 and December 2020, 10,217 primary joint arthroplasties were performed. Of those, 21% (2184 joints) were excluded; 2183 were in patients with multiple arthroplasties and one had no recorded BMI. All 8033 remaining joints were eligible for inclusion, 52% of which (4184) were THAs, 44% (3494) were TKAs, and 4% (355) were unicompartmental knee arthroplasties; all patients had 90 days of follow-up. The Wells score was used to guide the investigations. Indications for CT pulmonary angiography for suspected PE included pleuritic chest pain, reduced oxygen saturations, dyspnea, or hemoptysis. Indications for ultrasound scans for suspected proximal DVT included leg swelling, pain, warmth, or erythema. Distal DVTs were recorded as negative scans because we do not treat them with modified anticoagulation. The division of categories was set at BMI 40 kg/m 2 , a common clinical cutoff used in surgical eligibility algorithms. Patients were grouped according to WHO BMI categories to assess for the following confounding variables: sex, age, American Society of Anesthesiologists grade, joint replaced, VTE prophylaxis, grade of operative surgeon, and implant cement status., Results: We found no increase in the odds of PE or proximal DVT in any WHO BMI category. When comparing patients with BMI less than 40 kg/m 2 with those with a BMI of 40 kg/m 2 or higher, there was no difference in the odds of PE (0.8% [58 of 7506] versus 0.8% [four of 527]; OR 1.0 [95% CI 0.4 to 2.8]; p > 0.99) or proximal DVT (0.4% [33 of 7506] versus 0.2% [one of 527]; OR 2.3 [95% CI 0.3 to 17.0]; p = 0.72). Of those who received diagnostic imaging, 21% (59 of 276) of CT pulmonary angiograms and 4% (34 of 718) of ultrasounds were positive for patients with BMI less than 40 kg/m 2 compared with 14% (four of 29; OR 1.6 [95% CI 0.6 to 4.5]; p = 0.47) and 2% (one of 57; OR 2.7 [95% CI 0.4 to 18.6]; p = 0.51) for patients with BMI 40 kg/m 2 or higher. There was no difference in the percentage of CT pulmonary angiograms ordered (4% [276 of 7506] versus 5% [29 of 527]; OR 0.7 [95% CI 0.5 to 1.0]; p = 0.07) or ultrasounds ordered (10% [718 of 7506] versus 11% [57 of 527]; OR 0.9 [95% CI 0.7 to 1.2]; p = 0.49) for BMI less than 40 kg/m 2 and BMI 40 kg/m 2 or higher., Conclusion: Increased BMI should not preclude individuals from lower limb arthroplasty based on suspected risk of clinically important VTE. National VTE risk stratification tools should be based on evidence assessing clinically relevant VTE (specifically, proximal DVT, PE, or death of thromboembolism) only., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Objectives: The purpose of this study was to determine changes in urolith trends and factors associated with different urolith types in dogs from the Republic of Ireland and Northern Ireland between 2010 and 2020., Materials and Methods: A laboratory database was searched for canine urolith submissions between 2010 and 2020. Trends in urolith composition between 2014 and 2020, and associations between patient characteristics with each urolith type were evaluated., Results: A total of 1162 submissions were included. Struvite (39.0%), calcium oxalate (27.8%) and compound (10.2%) were the most prevalent uroliths. Calcium oxalate urolith (CaOx) incidence significantly increased from 27.8% to 31.2% and that of struvite significantly decreased from 41.7% to 33.0% between 2014 and 2020. Struvite uroliths were overrepresented among females compared to males (odds ratio 8.7, 95% confidence interval 6.6 to 11.5). Males (odds ratio 9.6, 95% confidence interval 6.9 to 13.3) and dogs >7 years of age (odds ratio 4.1, 95%, confidence interval 3.0 to 5.4) were more likely to have CaOx while males (odds ratio 9.6, 95% confidence interval 5.3 to 17.8) and dogs ≤7 year of age, purine uroliths (odds ratio 3.0, 95% confidence interval 1.8 to 5.0). Incidence was higher in bichon frise (odds ratio 1.7, 95% confidence interval 1.3 to 2.4) and Yorkshire terrier (odds ratio 2.8, 95% confidence interval 1.9 to 4.1) for CaOx and higher in shih-tzu for compound uroliths (odds ratio 1.7, 95% confidence interval 1.1 to 2.7) compared to the remaining reported breeds., Clinical Significance: Factors associated with different uroliths were similar to the ones previously reported. Proportion of CaOx submissions increased and that of struvite decreased over the study period which was in agreement with the changes identified in other European countries., (© 2023 British Small Animal Veterinary Association.)

Background: The practice of immediate sequential bilateral cataract surgery (ISBCS) was more widely adopted in the UK during the COVID-19 pandemic, in response to limited surgical capacity and the risk of nosocomial infection. This study reports on a single site experience of ISBCS in Northern Ireland., Methods: Data was collected prospectively between 17 th November 2020 and 30 th November 2021. The ISBCS surgical protocol, recommended by RCOphth and UKISCRS, was followed. Primary outcomes measures were: postoperative visual acuity (VA), refractive prediction accuracy, intraoperative and postoperative complications., Results: Of 41 patients scheduled, 39 patients completed ISBCS and two patients underwent unilateral surgery (n=80 eyes). Mean age at the time of surgery was 71.6 years (standard deviation (SD) ±11.8 years). Median preoperative VA was 0.8 logMAR (range: PL to 0.2 logMAR). Seventeen (20.9%) eyes were highly myopic and 9 (11.1%) eyes were highly hypermetropic. Median cumulative dissipated phacoemulsification energy was 15.7 sec (range: 1.8 sec to 83.4 sec). Median case time was 10.4 min (range: 4.3 min to 37.1 min).One eye (1.3%) developed iritis secondary to a retained tiny cortical fragment. Four eyes (5.0%, n=3 patients) developed cystoid macular oedema, with full resolution. On wide field imaging, an asymptomatic unilateral peripheral suprachoroidal haemorrhage was noted in two highly myopic patients (axial lengths of 27.01mm and 25.05mm respectively). The posterior pole was spared, and both resolved spontaneously without any visual impairment., Conclusions: In our initial experience, ISBCS was found to be a safe approach to cataract surgery. Our patient cohort included eyes with dense cataracts and high ametropia. Further studies are required to assess patient reported outcome measures and the possible economic benefits of ISBCS in our local population., Competing Interests: No authors declared conflicts of interest relating to this project., (Copyright © 2024 Ulster Medical Society.)

The potential for recreational abuse of the analgesic and antiepileptic drug pregabalin is now well established in the literature. The potential minimum lethal dose in post mortem cases is however less defined. All post mortem examinations in Northern Ireland where the cause of death was found to be due to pregabalin were examined for demographic and toxicological analysis. Deaths are generally seen in young men, especially 30-39-year-olds, many of whom have a history of substance misuse and are often prescribed pregabalin. Until recently, prescription rates have been on the rise regionally. The overall median post mortem peripheral blood concentration of pregabalin found in this study is 10.6 mg/L, however this rises when concurrent drugs and alcohol are considered and in cases where pregabalin is considered responsible for death alone (i.e. outside of multidrug toxicity). Pregabalin peripheral blood concentrations returned in this study suggest previously offered minimum lethal dosages may need to be revised downward., Competing Interests: Declaration of competing interest The authors declare no conflict of interest in the production of this work., (Copyright © 2023 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Background: Periprosthetic fractures are rare but devastating complications of knee replacement, often requiring complex surgery with substantial morbidity and mortality. It is not known how the fracture rates after total knee replacement (TKR) and unicompartmental knee replacement (UKR) compare. We performed the first matched study comparing TKR and UKR periprosthetic fracture rates., Methods: This study involved 54,215 UKRs and 54,215 TKRs, identified in the National Joint Registry and Hospital Episodes Statistics database, which were propensity score-matched on patient and surgical factors. The International Classification of Diseases, Tenth Revision, (ICD-10) code M96.6 was used to identify periprosthetic fractures at ≤3 and >3 months postoperatively, as well as estimate rates at up to 10 years. Subgroup analyses were performed in different age groups (<55, 55 to 64, 65 to 74, and ≥75 years), body mass index (BMI) categories (normal, 18.5 to <25 kg/m 2 ; overweight, 25 to <30 kg/m 2 ; obese, 30 to <40 kg/m 2 ; and morbidly obese, ≥40 kg/m 2 ), and sexes., Results: The 3-month fracture rate was 0.09% (n = 50) in the UKR group and 0.05% (n = 25) in the TKR group, with this difference being significant (odds ratio [OR], 2.0; p = 0.004). The rate of fractures occurring at >3 months was 0.32% (n = 171) in the UKR group and 0.61% (n = 329) in the TKR group (OR, 0.51; p < 0.001). At 10 years, the cumulative incidence of fractures was 0.6% after UKR versus 1% after TKR (OR, 0.68; p < 0.001). Fracture rates increased with increasing age, decreasing BMI, and female sex for both UKRs and TKRs., Conclusions: The fracture risk was small after both UKR and TKR, with small absolute differences between implant types. During the first 3 postoperative months, the fracture rate after UKR was 0.1% and was about twice as high as that after TKR. However, over the first 10 years, the cumulative fracture rate after TKR was 1% and was almost twice as high as that after UKR. Fracture rates after both UKR and TKR were higher in women, patients ≥75 years of age, and patients with normal weight., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H712 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

2023 marks the 25th anniversary of the Good Friday Agreement, which led peace in Northern Ireland. As well as its impact on peace and reconciliation, the Good Friday Agreement has also had a lasting positive impact on cancer research and cancer care across the island of Ireland. Pursuant to the Good Friday Agreement, a Memorandum of Understanding (MOU) was signed between the respective Departments of Health in Ireland, Northern Ireland and the US National Cancer Institute (NCI), giving rise to the Ireland - Northern Ireland - National Cancer Institute Cancer Consortium, an unparalleled tripartite agreement designed to nurture and develop linkages between cancer researchers, physicians and allied healthcare professionals across Ireland, Northern Ireland and the US, delivering world class research and better care for cancer patients on the island of Ireland and driving research and innovation in the US., Competing Interests: Declaration of Competing Interest ML declares honoraria from Bayer, Carnall Farrar, Novartis, Pfizer and Roche unrelated to this work, GKA declares research support from Agenus, Arcus, Astra Zeneca, BioNtech, BMS, Elicio, Genentech/Roche, Helsinn, Parker Institute, Pertzye, Puma, QED, Yiviva, and consulting support from Astellas, Astra Zeneca, Autem, Berry Genomics, BioNtech, Boehringer Ingelheim, BMS, Eisai, Exelixis, Fibriogen, Genentech/Roche, Incyte, Ipsen, Merck, Merus, Neogene, Novartis, Servier, Tempus, Thetis, Vector, Yiviva unrelated to this work RDL declares interests as Founder of CV6 Therapeutics (NI) Ltd, Belfast, UK unrelated to this work MAG declares interests as Founder of Aviceda Therapeutics and Aviceda Glycotech and as an equity shareholder of Aviceda Glycotech Ltd and Aviceda Therapeutics Inc unrelated to this work MLo declares advisory roles with AstraZeneca, Roche/Genentech, Servier and research funding from Astellas Pharma, Basilea, Exelixis and MSD unrelated to this work WMG declares interests as Co-Founder and Chief Scientific Officer, OncoAssure and Scientific Advisory Board member, Carrick Therapeutics unrelated to this work RS, KDMcC, DK, JF, WD, EM, JLG, CJS, DBL, ACC, NO, SJC, SG declare no competing interests, The opinions expressed in this article are the authors own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States Government., (Copyright © 2023. Published by Elsevier Ltd.)

Purpose: To report prevalence and risk factor associations for age-related macular degeneration (AMD) and AMD features from multimodal retinal grading in a multidisciplinary longitudinal population-based study of aging in Northern Ireland., Study Design: Population-based longitudinal cohort study., Methods: Retinal imaging at the Norther Ireland Cohort for the Longitudinal Aging Study health assessment included stereo Colour Fundus Photography (CFP) (Canon CX-1, Tokyo, Japan) and Spectral-Domain Optical Coherence Tomography (SD-OCT) ((Heidelberg Retinal Angopgraph (HRA)+OCT; Heidelberg Engineering, Heidelberg, Germany). Medical history and demographic information was obtained during a home interview. Descriptive statistics were used to describe the prevalence of AMD and individual AMD features. Multiple imputation followed by multiple regression modelling was used to explore risk factor associations including relationships with AMD genetic risk score., Results: Retinal images from 3386 participants were available for analysis. Mean age of the sample was 63.4 (SD 9.01, range: 36-99). Population weighted prevalence of AMD using colour grading in those over 55 years was: no drusen: 6 0.4%; drusen <63 μm: 15.9%; drusen 63-125 µm: 13.7%; drusen >125 µm or pigmentary changes: 8.3%; late AMD: 1.6%. Prevalence of AMD features in those over 55 years was: OCT drusen 27.5%, complete outer retinal pigment epithelium and outer retinal atrophy (cRORA) on OCT was 4.3%, reticular drusen 3.2% and subretinal drusenoid deposits 25.7%. The genetic risk score was significantly associated with drusen and cRORA but less so for SDD alone and non-significant for hyperpigmentation or vitelliform lesions., Conclusions: Multimodal imaging-based classification has provided evidence of some divergence of genetic risk associations between classical drusen and SDD. Our findings support an urgent review of current AMD severity classification systems., Competing Interests: Competing interests: Ruth Hogg: Optos PLC and Novartis; UC: Bayer. These all relate to non-restrictive grants awarded to QUB to support the retinal grading of this study., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: Many people living with cancer are admitted as an emergency, some just prior to diagnosis and others in their last year of life. Factors associated with accessing emergency care for people dying of cancer are complex and not well understood. This can make it difficult to have the resources and staffing in place to best care for individuals in their last year of life and their families., Methods: This study uses routinely collected administrative data from people who died of cancer in N. Ireland (NI) during 2015 and explores how personal characteristics (e.g., gender, age) and disease related factors (e.g., tumour site, cancer stage at initial diagnosis) were associated with having an emergency admission to hospital in the last year and the last 28 days of their lives, using multivariate logistic regression., Results: Almost three in four people had at least one emergency admission in the last year of life, and over one in three had an emergency admission the last 28 days of life. Patterns were similar for both time outcomes with males, people with haematological, lung or brain cancers, younger persons, those diagnosed with late-stage cancer, and people diagnosed close to time of death, being significantly more likely to have an emergency admission. While there was no significant association between deprivation and emergency admission rates, those living in urban areas were more likely to have an emergency admission in their last month of life compared to rural dwellers. Late diagnosis was evident with 538 people (12.8% of all deaths from cancer) being diagnosed within one month of death and 1242 (29%) within 3 months of death., Conclusion: The high level of emergency admissions points to gaps in routine end-of-life care, and the need for additional training for hospital staff including frontline emergency department (ED) staff who are often the 'gatekeepers' to emergency inpatient care for people living with cancer. The levels of late diagnosis indicate a need for increased population awareness of cancer symptoms and system change to promote earlier diagnosis., (© 2023. The Author(s).)

The global drug market has been significantly impacted by the emergence of new psychoactive substances, leading to challenges in creating effective legislative controls and their use within recreational drug consumption. This research explores the prevalence of new psychoactive substances and non-medicinal and medicinal compounds within a prison facility in Northern Ireland. Wastewater samples collected from seven different manholes within the prison were analysed for 37 target compounds including the two most found illicit substances: benzoylecgonine (primary metabolite of cocaine) and cannabis. Using solid phase extraction with Oasis HLB and liquid-chromatography-time-of-flight-mass spectrometry across a gradient of 9 min, our analysis revealed that benzoylecgonine was the sole compound consistently present in all collected samples. Following this finding, our target compound selection was broadened to encompass medicinal compounds and employing qualitative analysis we re-evaluated the samples and discovered the presence of buprenorphine, benzodiazepines, methadone, morphine, and codeine. Finally, the study explored the application of enzymatic beta-glucuronidase hydrolysis to the samples. This final phase yielded significant findings, indicating the presence of codeine and nordiazepam at higher peak intensities, thereby shedding light on the potential implications of this enzymatic process., (© 2023. The Author(s).)

We report cases of mammalian infection with highly pathogenic avian influenza (HPAI) virus A(H5N1) clade 2.3.4.4b in Northern Ireland. Two common gulls ( Larus canus ) and two red fox kits ( Vulpes vulpes ), were found dead in close vicinity. Comparison of viral whole genome sequences obtained from the animals identified a novel mammalian adaptation, PB2-M535I. Analysis of genetic sequences from other recent mammalian infections shows that this mutation has arisen on at least five occasions in three European countries since April 2023.

Objective: The incidence of congenital hypothyroidism (CHT) has progressively increased in several regions around the world but has yet to be evaluated in Northern Ireland (NI). CHT screening programme was introduced in NI in 1980 and has had a relatively unchanged protocol since its inception. The purpose of the study was to evaluate the incidence of CHT in NI from 1981 to 2020 and to explore possible contributing factors to any changes seen over the 40-year period., Design: This was a retrospective database review of children diagnosed with CHT in NI between 1981 and 2020. Data was collected from the patients' medical (paper and electronic) records, including epidemiological, clinical, laboratory, and radiological features as well as outcomes at 3 years., Results: Of 800,404 new-borns who were screened for CHT in NI between January 1981 and March 2020, 471 were diagnosed with CHT. There was a steady and significant increase in incidence of CHT over time with an incidence of 26 cases per 100,000 livebirths in 1981 versus 71 cases per 100,000 in 2019 (p < .001). Of these 471, 77 new-borns (16%) were born preterm. The incidence of CHT was observed twice as much in female compared to male new-borns. Diagnostic imaging including radioisotope uptake and thyroid ultrasound scans were performed in 143 cases (30%). Of these, 101 (70%) cases had thyroid dysgenesis and 42 (30%) cases had thyroid dyshormonogenesis. There were 293 (62%) of 471 patients had confirmed permanent CHT, and 90 patients (19%) had transient CHT. Over that period at least 95% of the population were recorded as having United Kingdom/Ireland as country of birth., Conclusion: Our findings demonstrate a nearly tripling of the CHT incidence observed over the last 40 years. This is against a background of a relatively stable population demographics. Future research should focus on the underlying cause(s) of this condition which may include changing environmental exposures in utero., (© 2023 John Wiley & Sons Ltd.)

Aim: To evaluate the impact of the COVID-19 pandemic on the patterns of antimicrobial use and the incidence of pathogens in primary and secondary healthcare settings in Northern Ireland., Methods: Data were collected on antibiotic use and Gram-positive and Gram-negative pathogens from primary and secondary healthcare settings in Northern Ireland for the period before (January 2015-March 2020) and during (April 2020-December 2021) the pandemic. Time series intervention analysis methods were utilized., Results: In the hospital setting, the mean total hospital antibiotic consumption during the pandemic was 1864.5 defined daily doses (DDDs) per 1000 occupied-bed days (OBD), showing no significant change from pre-pandemic (P = .7365). During the pandemic, the use of second-generation cephalosporins, third-generation cephalosporins, co-amoxiclav and levofloxacin increased, there was a decrease in the percentage use of the hospital Access group (P = .0083) and an increase in the percentage use of Watch group (P = .0040), and the number of hospital Klebsiella oxytoca and methicillin-susceptible Staphylococcus aureus cases increased. In primary care, the mean total antibiotic consumption during the COVID-19 pandemic was 20.53 DDDs per 1000 inhabitants per day (DID), compared to 25.56 DID before the COVID-19 pandemic (P = .0071). During the pandemic, there was a decrease in the use of several antibiotic classes, an increase in the percentage use of the Reserve group (P = .0032) and an increase in the number of community-onset Pseudomonas aeruginosa cases., Conclusion: This study provides details of both changes in antibiotic consumption and the prevalence of infections in hospitals and primary care before and during the COVID-19 pandemic that emphasize the importance of antimicrobial stewardship in pandemic situations., (© 2023 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Haemolytic uraemic syndrome (HUS) caused by infection with Shiga toxin-producing Escherichia coli (STEC) is a relatively rare but potentially fatal multisystem syndrome clinically characterised by acute kidney injury. This study aimed to provide robust estimates of paediatric HUS incidence in England, Wales, Northern Ireland, and the Republic of Ireland by using data linkage and case reconciliation with existing surveillance systems, and to describe the characteristics of the condition. Between 2011 and 2014, 288 HUS patients were included in the study, of which 256 (89.5%) were diagnosed as typical HUS. The crude incidence of paediatric typical HUS was 0.78 per 100,000 person-years, although this varied by country, age, gender, and ethnicity. The majority of typical HUS cases were 1 to 4 years old (53.7%) and female (54.0%). Clinical symptoms included diarrhoea (96.5%) and/or bloody diarrhoea (71.9%), abdominal pain (68.4%), and fever (41.4%). Where STEC was isolated (59.3%), 92.8% of strains were STEC O157 and 7.2% were STEC O26. Comparison of the HUS case ascertainment to existing STEC surveillance data indicated an additional 166 HUS cases were captured during this study, highlighting the limitations of the current surveillance system for STEC for monitoring the clinical burden of STEC and capturing HUS cases.

Background: While smoking prevalence in high income countries has declined over time, socioeconomic inequalities in smoking have widened. This study is one of the few studies to examine the longitudinal pattern of income-related smoking inequalities and only the second using concentration indices in its analysis., Method: Income-related smoking inequalities were measured using concentration indices using the Northern Ireland Continuous Household Survey data. Smoking inequalities were compared quantitatively and visually across three periods: 1985-1995, 1997-2005 and 2007-2015. Joinpoint analysis was used to measure the overall time trend of smoking inequalities. Subgroup analysis was used to examine the nature of change in smoking inequalities across population sub-groups., Findings: Throughout 1985-2015, smoking was more concentrated among the poor (standard concentration index of-0·131, p < 0·001). While prevalence declined sharply across population, income-related inequalities increased sharply in general and within subgroups. Income-related smoking inequalities were significantly larger among high educated group and those who were employed. No structural break was observed with respect to the adoption of any specific policy measures over the period., Conclusion: Current approaches to tobacco control may be ill-suited to addressing smoking inequalities and may indeed be counterproductive. More tailored approaches that address the specific needs of population sub-groups or more draconian approaches such as extensions to prohibition may be required to reduce prevalence further while avoiding a widening of inequalities., Competing Interests: Declaration of Competing Interest We declare no competing interests., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: People with severe mental illness (SMI) die prematurely, mostly due to preventable causes., Objective: To examine multimorbidity and mortality in people living with SMI using linked administrative datasets., Method: Analysis of linked electronically captured routine hospital administrative data from Northern Ireland (2010-2021). We derived sex-specific age-standardised rates for seven chronic life-limiting physical conditions ( chronic kidney disease, malignant neoplasms, diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure, myocardial infarction, and stroke ) and used logistic regression to examine the relationship between SMI, socio-demographic indicators, and comorbid conditions; survival models quantified the relationship between all-cause mortality and SMI., Results: Analysis was based on 929,412 hospital patients aged 20 years and above, of whom 10,965 (1.3%) recorded a diagnosis of SMI. Higher likelihoods of an SMI diagnosis were associated with living in socially deprived circumstances, urbanicity. SMI patients were more likely to have more comorbid physical conditions than non-SMI patients, and younger at referral to hospital for each condition, than non-SMI patients. Finally, in fully adjusted models, SMI patients had a twofold excess all-cause mortality., Conclusion: Multiple morbidities associated with SMI can drive excess mortality. While SMI patients are younger at referral to treatment for these life-limiting conditions, their relatively premature death suggests that these conditions are also quite advanced. There is a need for a more aggressive approach to improving the physical health of this population.

Background: The majority of Northern Irish uveal melanoma (UM) patients are diagnosed in Sheffield. This study aims to present incidence and survival outcomes for UM patients from Northern Ireland (NI)., Methods: Collaborative retrospective study between Sheffield and Northern Ireland Cancer Registry (NICR). For UM cases not on both databases, outcomes and survival rates (via Kaplan-Meier analysis) were compared. Anonymised NICR data were used to calculate whole-population incidence of UM for NI., Results: In total, 161 patients from NI were diagnosed in Sheffield, 90 of which were not registered with NICR at the start of this study. Data-omissions were not consistent across patient groups, leading to significant differences between those patients registered and those not. Registered patients had an all-cause 5-year survival rate of only 68.9% compared to 92.5% of those not registered (p < 0.01) and were >17x more likely to have systemic metastases than those not registered (p < 0·001). Following rectification of data-omissions, the European age-standardised incidence rate of UM for NI was 8·6 per million., Conclusions: This study illustrates the impact of incomplete population-wide data, serving as a real-world lesson in case-identification bias. Rare cancers are at higher risk of omission due to systemic failures as the small numbers involved are not detected by system-wide validation procedures. Following this study, data-transfer agreements between England and NI were actioned, preventing future data-omissions. We present survival and incidence data for UM in NI for the first time, showing the incidence is amongst the highest in Europe, with good survival rates., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Background: The COVID-19 pandemic was managed in Aotearoa New Zealand (NZ) by a COVID-19 elimination policy, involving border closure and an initial national lockdown. This was different to most other countries including Northern Ireland (NI) and the Netherlands (NED). We quantify the effect of these policies on the diagnosis of three major cancers, comparing NZ with these two European countries., Method: Data from NED, NZ and NI population-based cancer registries were used to assess trends in all pathologically diagnosed (PD) lung, breast, and colorectal cancers from March to December 2020 (pandemic period) and compared to the similar pre-pandemic period (2017-2019). Trend data were also collated on COVID-19 cases and deaths per 100,000 in each population., Results: Comparing the pre-pandemic period to the pandemic period there were statistically significant reductions in numbers of lung (↓23%) and colorectal (↓15%) PD cancers in NI and numbers of breast (↓18%) and colorectal cancer (↓18.5%) diagnosed in the NED. In NZ there was no significant change in the number of lung (↑10%) or breast cancers (↑0.2%) but a statistically significant increase in numbers of colorectal cancer diagnosed (↑5%)., Conclusion: The impact of COVID-19 on cancer services was mitigated in NZ as services continued as usual reflecting minimal healthcare disruption and protected cancer services linked with the elimination approach adopted. The reduction in PD cases diagnosed in NED and NI were linked with higher COVID-19 rates and reflect societal restrictions which resulted in delayed patient presentation to primary and secondary care, disruption to screening and healthcare services as a result of COVID-19 infections on staff and the need to shift intensive care to COVID-19 patients. Reductions in PD cancers in NI and the NED and in particularly lung cancers in NI, highlight the need for targeted public health campaigns to identify and treat 'missing' patients. Protecting cancer services should be a priority in any future pandemic or systemic healthcare system disruption., (© 2023. The Author(s).)

Bovine tuberculosis (bTB) is a chronic, zoonotic infection of domestic and wild animals caused mainly by Mycobacterium bovis. The Test and Vaccinate or Remove (TVR) project was a 5-year intervention (2014-2018) applied to Eurasian badgers ( Meles meles ) in a 100 km 2 area of County Down, Northern Ireland. This observational study used routine bTB surveillance data of cattle to determine if the TVR intervention had any effect in reducing the infection at a herd level. The study design included the TVR treatment area (Banbridge) compared to the three adjacent 100 km 2 areas (Dromore, Ballynahinch, and Castlewellan) which did not receive any badger intervention. Results showed that there were statistically lower bTB herd incidence rate ratios in the Banbridge TVR area compared to two of the other three comparison areas, but with bTB herd history and number of bTB infected cattle being the main explanatory variables along with Year. This finding is consistent with other study results conducted as part of the TVR project that suggested that the main transmission route for bTB in the area was cattle-to-cattle spread. This potentially makes any wildlife intervention in the TVR area of less relevance to bTB levels in cattle. It must also be noted that the scientific power of the TVR study (76%) was below the recommended 80%, meaning that results must be interpreted with caution. Even though statistical significance was achieved in two cattle-related risk factors, other potential risk factors may have also demonstrated significance in a larger study.

Background: Self-harm is a recognised predictor of suicide and is most common in those aged under 25 years. The aims of this study were to describe the characteristics of young people who present with self-harm; quantify the risk of suicide and other causes of death during follow up, and to identify factors associated with mortality risk., Methods: The Northern Ireland Registry of Self-Harm (NIRSH) is a national registry capturing complete data on all presentations made to the 12 Emergency Departments (EDs) in Northern Ireland (NI). Data relating to self-harm presentations registered in the NIRSH between 2012 and 2015 were linked to primary care registrations and death records up until 31st December 2018. Logistic regression was employed to examine the factors associated with self-harm. Cox regression was used to estimate mortality risk following self-harm and explore the associated risk factors., Results: The cohort consisted of 390,740 individuals aged 10-24 years registered with a General Practitioner (GP) in NI. During follow-up, 4,450 individuals presented with self-harm. Rates of self-harm were highest in females, those aged 20-24 years (OR adj  = 3.53, 95% CI 3.28-3.80, p < .001), and in the most deprived areas (OR adj  = 2.71, 95% CI 2.45-2.99, p < .001). Thirty five individuals who presented with self-harm died by suicide, accounting for 23% of all suicide deaths in the cohort. Suicide risk was increased 19-fold in those who presented with self-harm after adjustment for age, sex and area-level factors (HR adj  = 19.00, 95% CI 12.80-28.21, p < .001). Increased suicide risk was observed in males (HR adj  = 2.04, 95% CI 0.99-4.23, p = .05) and those using more violent methods of self-injury (HR adj  = 3.89, 95% CI 1.65-9.13, p < .001)., Conclusions: Young people who self-harm are at a significantly greater risk of suicide. Almost a quarter of young people who died by suicide in NI had presented to EDs with self-harm, highlighting that the ED may provide a nodal point of intervention among a typically hard to identify and reach population., (© 2023 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

Background: The aim of this study is to 1) explore the experiences of people living with dementia interacting with DFCs and 2) identify factors that influence empower and support people living with dementia to live successfully in DFCs. The main elements of a DFC are related to people; communities; organisations and partnerships. There are over 200 organisations recognised as dementia-friendly in Northern Ireland (NI). This realist evaluation is to understand how DFCs work for people living with dementia, how positive outcomes are achieved, for whom and in what contexts do DFCs work best., Methods: A realist evaluation using case study methodology. The process evaluation includes a realist review of the literature, non-participant observation of people living with dementia in their local communities, semi-structured interviews to explore the facilitators and barriers to living well in DFCs and focus groups comprised of people living with dementia, family caregivers and people working in DFCs to support Context- Mechanisms and Outcomes (CMOs). This four-stage realist assessment cycle is used, including iterative rounds of theory development, data gathering, and theory testing. In the end, analysis will reveal context mechanisms that influence how dementia-friendly communities operate and present an initial theory of how people think, which, if adopted, may be able to alter current contexts so that "key" mechanisms are activated to generate desired outcomes., Discussion: To give confidence in moving from hypothetical constructions about how DFCs could function to explanations of possible or observable causal mechanisms, the realist evaluation of a complex intervention incorporates a variety of evidence and perspectives. Despite playing a significant role in a person with dementia's everyday life, it appears that little is known about how communities function to achieve intended results. Even though there has been a lot of work to pinpoint the fundamentals and crucial phases of building DFCs, it is still unclear how people living with dementia benefit the most from these communities. This study intends to advance our understanding of how outcomes are produced for people living with dementia by contributing to the underlying theory of DFCs as well as addressing the primary research objectives., (© 2023. The Author(s).)

Background: While evidence has emerged highlighting the potential benefits of the eye as a window to the central nervous system, research on severe mental illness (SMI) and eye health is rare., Aims: We examine the association of SMI with a range of ophthalmic health outcomes, and whether any relationship is modified by age., Methods: We used linked administrative data from general practitioner (GP), hospital and ophthalmic records to examine receipt of any Health and Social Care (HSC) eye-test; and (based on eligibility recorded for a sight test) any glaucoma, any diabetes, and any blindness among the Northern Ireland (NI) hospital population between January 2015 and November 2019 (N = 798,564)., Results: When compared with non-SMI patients, those with SMI recorded a higher prevalence of having had a sight test, diabetes, and blindness. In fully adjusted logistic regression models, higher likelihood of an eye-test and diabetes (OR = 1.71: 95%CI = 1.63, 1.79 and OR = 1.29: 1.19, 1.40 respectively); and lower likelihood of glaucoma remained (OR = 0.69: 0.53, 0.90). Amongst persons with SMI there was evidence that the likelihood of having had an eye-test was lower in the older age-groups., Conclusion: Our study provides new evidence on ophthalmic health inequalities associated with SMI. While the study has immediate relevance to its NI context, we believe it is generalizable to wider UK health concerns. We emphasize the need for more research of this type, using large linkable electronic administrative databases to further our understanding of both health inequalities associated with SMI and poor eye health, and health outcomes in general., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ferry et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction:  Perinatal or neonatal testicular torsion (PTT) is defined as testicular torsion within the first 30 days of life. PTT is a rare event, and bilateral PTT is even rarer. However, recent articles have advocated emergency bilateral exploration to exclude the catastrophic possibility of asymptomatic contralateral testicular torsion leading to anorchia. The aim of this study is to evaluate PTT in Northern Ireland (NI) using a nationwide population-based retrospective observational study., Methods:  All boys in NI who underwent emergency scrotal exploration within their first 30 days of life for possible testicular torsion over a 10-year period (January 2010-December 2019 inclusive) were included. Intraoperative findings primarily evaluated included diagnosis and presence of synchronous or asynchronous (metachronous) contralateral testicular torsion. Secondary outcomes included correlation between intraoperative findings and any preoperative ultrasound scan (USS), and scrotal examination findings during postoperative outpatient follow-up., Results:  A total of 19 patients who underwent emergency scrotal exploration in the study period were included. An intraoperative finding confirming the diagnosis of PTT was reported in 14 (73.7%) patients. The incidence of PTT was calculated as 11.3 per 100,000 per male live births in NI, with bilateral PTT accounting for two patients (14.2% of all PTTs), divided equally between synchronous and asynchronous PTTs. Of two affected testes where preservation was felt appropriate intraoperatively, only one was still palpable at follow-up, producing a testicular salvage rate after PTT of only 7.1%. Testicular findings on preoperative USS were confirmed intraoperatively in five out of six patients, producing a concordance rate of 83.3%., Conclusion:  This is the first nationwide population-based study to calculate more accurately the incidence of PTT, and bilateral synchronous and asynchronous bilateral PTTs, all of which seem to be significantly higher than previously estimated. However, in keeping with previous reports, this study confirms the poor salvage rate of testes undergoing perinatal torsion, and suboptimal concordance between preoperative USS findings and intraoperative diagnosis., Competing Interests: None declared., (Thieme. All rights reserved.)