A retrospective cohort study of differential attainment, COVID and Chaos: taking the difference out of a terrible trinity.

BACKGROUND: This study aimed to evaluate Core Surgical Training (CST) differential attainment related to COVID-19, gender, and ethnicity. The hypothesis was that COVID-19 adversely influenced CST outcomes. METHODS: A retrospective cohort study of 271 anonymised CST records was undertaken at a UK Statutory Education Body. Primary effect measures were: Annual Review of Competency Progression Outcome (ARCPO), Membership of the Royal College of Surgeons (MRCS) examination pass, and Higher Surgical Training National Training Number (NTN) appointment. Data was collected prospectively at ARCP and analysed with non-parametric statistical methods in SPSS®. RESULTS: CSTs numbering 138 completed training pre- and 133 peri-COVID. ARCPO 1,2&6 were 71.9% pre- vs. 74.4% peri-COVID (P=0.844). MRCS pass rates were 69.6% pre- versus 71.1% peri-COVID (P=0.968) but NTN appointment rates diminished (pre- 47.4% vs. peri- 36.9%, P=0.324); none of the above varied by gender or ethnicity. Multivariable analyses by three models revealed: ARCPO was associated with gender (m: f 1:0.87, OR 0.53, P=0.043) and CST theme (Plastics vs. General OR 16.82, P=0.007); MRCS pass with theme (Plastics vs. General OR 8.97, P=0.004); NTN with the Improving Surgical Training run-through program (OR 5.00, P<0.001). Program retention improved peri-COVID (OR 0.20, P=0.014) with pan University Hospital rotations performing better than Mixed or District General-only rotations (OR 6.63, P=0.018). CONCLUSION: Differential attainment profiles varied 17-fold, yet COVID-19 did not influence ARCPO or MRCS pass rates. NTN appointment fell by one fifth peri-COVID, but overall training outcome metrics remained robust despite the existential threat.

First uterine transplant case at the Royal Prince Alfred Hospital.

Uterine transplantation (UT) is an emerging medical treatment for women affected by absolute uterine factor infertility (AUFI). To date there have been over 90 documented cases of UT performed worldwide, with over 50 live births. UT allows women affected by AUFI the opportunity to carry and deliver a childd. The Royal Prince Alfred Hospital (RPAH) introduced a UT study in 2019; however, due to the impacts of the COVID pandemic the study was placed on hold for two years. In February 2023, RPAH performed the centre's first UT from a living unrelated donor to a 25-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome. The donor and recipient surgeries were uncomplicated and both are recovering well in the early post-operative period.

Utility of COVID-19 antigen testing in the emergency department.

BACKGROUND: The BinaxNOW coronavirus disease 2019 (COVID-19) Ag Card test (Abbott Diagnostics Scarborough, Inc.) is a lateral flow immunochromatographic point-of-care test for the qualitative detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid protein antigen. It provides results from nasal swabs in 15 minutes. Our purpose was to determine its sensitivity and specificity for a COVID-19 diagnosis. METHODS: Eligible patients had symptoms of COVID-19 or suspected exposure. After consent, 2 nasal swabs were collected; 1 was tested using the Abbott RealTime SARS-CoV-2 (ie, the gold standard polymerase chain reaction test) and the second run on the BinaxNOW point of care platform by emergency department staff. RESULTS: From July 20 to October 28, 2020, 767 patients were enrolled, of which 735 had evaluable samples. Their mean (SD) age was 46.8 (16.6) years, and 422 (57.4%) were women. A total of 623 (84.8%) patients had COVID-19 symptoms, most commonly shortness of breath (n = 404; 55.0%), cough (n = 314; 42.7%), and fever (n = 253; 34.4%). Although 460 (62.6%) had symptoms ≤7 days, the mean (SD) time since symptom onset was 8.1 (14.0) days. Positive tests occurred in 173 (23.5%) and 141 (19.2%) with the gold standard versus BinaxNOW test, respectively. Those with symptoms >2 weeks had a positive test rate roughly half of those with earlier presentations. In patients with symptoms ≤7 days, the sensitivity, specificity, and negative and positive predictive values for the BinaxNOW test were 84.6%, 98.5%, 94.9%, and 95.2%, respectively. CONCLUSIONS: The BinaxNOW point-of-care test has good sensitivity and excellent specificity for the detection of COVID-19. We recommend using the BinasNOW for patients with symptoms up to 2 weeks.

Health behaviors and subsequent mental health problems during the COVID-19 pandemic: A longitudinal analysis of adults in the UK.

Introduction: Public health mitigation policies aimed at slowing the spread of COVID-19 led to an increase in mental health problems (MHPs). This study examines the association between multiple pre-pandemic health behaviors and MHPs prior to, and during, the COVID-19 pandemic. Methods: We analyzed a representative population sample of 11,256 adults (aged 20-65 years) from Understanding Society-The UK Household Longitudinal Study. Baseline data from participants interviewed in 2017/2019 (wave 9) were linked to web surveys conducted during the COVID-19 pandemic. We used latent class analysis (LCA) to identify mutually exclusive health behavior (physical activity, alcohol consumption, eating habits and smoking tobacco) clusters by gender, and examined the sociodemographic correlates of each cluster. We assessed how pre-pandemic latent classes of health behaviors were associated with changes in MHPs during the pandemic using fixed effects regression models. Results: Three health behavior clusters were identified: positive (33%), moderate (24%), and high risk (43%), where similar behaviors clustered within individuals and sociodemographic circumstances. In particular, gender, age, migrant status and ethnicity were found to have strong associations with each cluster. Our results also demonstrated a clear association in MHPs with health behaviors both prior to, and during the pandemic. There were significant increases in MHPs between 2017/2019 and January 2021, with fluctuations coinciding with changes in public health mitigation policies. Assessments across the three clusters showed about 25.2%, 16.9%, and 0.7% increases in MHPs in the positive, moderate and high risk health behavior clusters, respectively. Discussion: This study shows that pre-pandemic health behaviors were significantly associated with mental health before and during the pandemic. Holistic policy interventions and promotions targeting multiple health behaviors may be an effective strategy to improve mental health in the pandemic recovery period.

Risk factors and outcomes of delirium in hospitalized older adults with COVID-19: a systematic review and meta-analysis

Background Older adults with COVID-19 are more likely to present with atypical symptoms, notably delirium. The main objective of this meta-analysis is to identify risk factors for delirium and outcomes of delirium in hospitalized older adults (65 years or above) with COVID-19. Methods Comprehensive literature search of Embase, CINAHIL, Medline and Web of Science was performed for published literature until 31st August 2021. Two independent researchers evaluated study eligibility and assessed study quality using the Newcastle Ottawa Scale (NOS) for cohort studies and Joanna Briggs Institute (JBI) critical appraisal tools for case series. The association of various predisposing factors with delirium in this cohort was reported as odds ratio (OR) and its 95% confidence interval (CI). Results A total of 31 studies from 11 countries were included in this review. Most of the included studies investigated patients from non-ICU settings (n=24;77.4%). Frailty (OR 3.52, 95% CI: 1.96-6.31, p<0.0001, I2=71.63%), cognitive impairment including dementia (OR 6.17, 95% CI: 2.92-13.07, p<0.00001, I2=88.63%) and being nursing home residents (OR 1.72, 95% CI: 1.31-2.24, p<0.0001, I2=0) were significantly associated with increased likelihood of developing delirium in older adults with COVID-19. The presence of delirium also significantly increases mortality risk in hospitalized older adults with COVID-19 (OR 2.51, 95% CI: 1.51-4.17, p<0.0001, I2=89.3%). Conclusion Our review identifies key factors associated with increased risk of developing delirium in hospitalized older adults with COVID-19. Identification of patients at risk of delirium and attention to these factors early during admission may improve outcomes for this vulnerable cohort.

Health behaviors and subsequent mental health problems during the COVID-19 pandemic: A longitudinal analysis of adults in the UK

Introduction Public health mitigation policies aimed at slowing the spread of COVID-19 led to an increase in mental health problems (MHPs). This study examines the association between multiple pre-pandemic health behaviors and MHPs prior to, and during, the COVID-19 pandemic. Methods We analyzed a representative population sample of 11,256 adults (aged 20–65 years) from Understanding Society—The UK Household Longitudinal Study. Baseline data from participants interviewed in 2017/2019 (wave 9) were linked to web surveys conducted during the COVID-19 pandemic. We used latent class analysis (LCA) to identify mutually exclusive health behavior (physical activity, alcohol consumption, eating habits and smoking tobacco) clusters by gender, and examined the sociodemographic correlates of each cluster. We assessed how pre-pandemic latent classes of health behaviors were associated with changes in MHPs during the pandemic using fixed effects regression models. Results Three health behavior clusters were identified: positive (33%), moderate (24%), and high risk (43%), where similar behaviors clustered within individuals and sociodemographic circumstances. In particular, gender, age, migrant status and ethnicity were found to have strong associations with each cluster. Our results also demonstrated a clear association in MHPs with health behaviors both prior to, and during the pandemic. There were significant increases in MHPs between 2017/2019 and January 2021, with fluctuations coinciding with changes in public health mitigation policies. Assessments across the three clusters showed about 25.2%, 16.9%, and 0.7% increases in MHPs in the positive, moderate and high risk health behavior clusters, respectively. Discussion This study shows that pre-pandemic health behaviors were significantly associated with mental health before and during the pandemic. Holistic policy interventions and promotions targeting multiple health behaviors may be an effective strategy to improve mental health in the pandemic recovery period.

Risk factors and outcomes of delirium in hospitalized older adults with COVID-19: A systematic review and meta-analysis.

Background: Older adults with COVID-19 are more likely to present with atypical symptoms, notably delirium. The main objective of this meta-analysis is to identify risk factors for delirium and outcomes of delirium in hospitalized older adults (65 years or above) with COVID-19. Methods: Comprehensive literature search of Embase, CINAHIL, Medline and Web of Science was performed for published literature until 31st August 2021. Two independent researchers evaluated study eligibility and assessed study quality using the Newcastle Ottawa Scale (NOS) for cohort studies and Joanna Briggs Institute (JBI) critical appraisal tools for case series. The association of various predisposing factors with delirium in this cohort was reported as odds ratio (OR) and its 95% confidence interval (CI). Results: A total of 31 studies from 11 countries were included in this review. Most of the included studies investigated patients from non-ICU settings (n = 24; 77.4%). Frailty (OR 3.52, 95% CI: 1.96-6.31, p<0.0001, I2=71.63%), cognitive impairment including dementia (OR 6.17, 95% CI: 2.92-13.07, p<0.00001, I2=88.63%) and being nursing home residents (OR 1.72, 95% CI: 1.31-2.24, p<0.0001, I2=0) were significantly associated with increased likelihood of developing delirium in older adults with COVID-19. The presence of delirium also significantly increases mortality risk in hospitalized older adults with COVID-19 (OR 2.51, 95% CI: 1.51-4.17, p<0.0001, I2=89.3%). Conclusion: Our review identifies key factors associated with increased risk of developing delirium in hospitalized older adults with COVID-19. Identification of patients at risk of delirium and attention to these factors early during admission may improve outcomes for this vulnerable cohort.

Face validity of a virtual reality simulation platform to improve competency in endoscopy: a prospective observational cohort study.

Background and study aims Virtual reality endoscopic simulation training has the potential to expedite competency development in novice trainees. However, simulation platforms must be realistic and confer face validity. This study aimed to determine the face validity of high-fidelity virtual reality simulation (EndoSim, Surgical Science, Gothenburg), and establish benchmark metrics to guide the development of a Simulation Pathway to Improve Competency in Endoscopy (SPICE). Methods A pilot cohort of four experts rated simulated exercises (Likert scale score 1-5) and following iterative development, 10 experts completed 13 simulator-based endoscopy exercises amounting to 859 total metric values. Results Expert metric performance demonstrated equivalence ( P  = 0.992). In contrast, face validity of each exercise varied among experts (median 4 (interquartile range [IQR] 3-5), P  < 0.003) with Mucosal Examination receiving the highest scores (median 5 [IQR 4.5-5], P  = 1.000) and Loop Management and Intubation exercises receiving the lowest scores (median 3 [IQR 1-3], P  < 0.001, P  = 0.004), respectively. The provisional validated SPICE comprised 13 exercises with pass marks and allowance buffers defined by median and IQR expert performance. Conclusions EndoSim Face Validity was very good related to early scope handling skills, but more advanced competencies and translation of acquired clinical skills require further research within an established training program. The existing training deficit with superadded adverse effects of the COVID pandemic make this initiative an urgent priority.

Prognostic significance of competition ratios in surgical specialty training selection.

BACKGROUND: A competition ratio (CR) indicates the ratio of total applications for a training post when compared with numbers of specialty posts available. This study aimed to evaluate CRs' influence on National Training Number (NTN) selection in a single UK Statutory Education Body. METHODS: Consecutive core surgical trainees numbering 154 (105 men, 49 women; median years since graduation: four) were studied over a 6-year period. Annual specialty specific CRs were obtained from Health Education England's website, and primary outcome measure was UK NTN appointment. RESULTS: Overall NTN appointment was 45.5%. Median CR was 2.36; range Oral & Maxillofacial Surgery 0.70 (2020) to Neurosurgery 22.0 (2020). Multivariable analysis revealed that NTN success was associated with: CR (OR 0.46, p=0.003), a single scientific publication (OR 6.25, p=0.001), cohort year (2019, OR 12.65, p=0.003) and Universal Annual Review of Competence Progression Outcome 1 (OR 45.24, p<0.001). CRs predicted NTN appointment with a Youden index defined critical ratio of 4.42; 28.6% (n=8) versus 49.2% (n=62), p=0.018. CONCLUSION: CRs displayed 30-fold variation, with CRs below 4.42 associated with twofold better NTN promotion, but strong clinical competence and academic reach again emerged as the principal drivers of career advancement.

Evaluation of the mental health impacts of Universal Credit: protocol for a mixed methods study.

INTRODUCTION: The UK social security system is being transformed by the implementation of Universal Credit (UC), which combines six existing benefits and tax credits into a single payment for low-income households. Despite extensive reports of hardship associated with the introduction of UC, no previous studies have comprehensively evaluated its impact on mental health. Because payments are targeted at low-income households, impacts on mental health will have important consequences for health inequalities. METHODS AND ANALYSIS: We will conduct a mixed methods study. Work package (WP) 1 will compare health outcomes for new recipients of UC with outcomes for legacy benefit recipients in two large population surveys, using the phased rollout of UC as a natural experiment. We will also analyse the relationship between the proportion of UC claimants in small areas and a composite measure of mental health. WP2 will use data collected by Citizen's Advice to explore the sociodemographic and health characteristics of people who seek advice when claiming UC and identify features of the claim process that prompt advice-seeking. WP3 will conduct longitudinal in-depth interviews with up to 80 UC claimants in England and Scotland to explore reasons for claiming and experiences of the claim process. Up to 30 staff supporting claimants will also be interviewed. WP4 will use a dynamic microsimulation model to simulate the long-term health impacts of different implementation scenarios. WP5 will undertake cost-consequence analysis of the potential costs and outcomes of introducing UC and cost-benefit analyses of mitigating actions. ETHICS AND DISSEMINATION: We obtained ethical approval for the primary data gathering from the University of Glasgow, College of Social Sciences Research Ethics Committee, application number 400200244. We will use our networks to actively disseminate findings to UC claimants, the public, practitioners and policy-makers, using a range of methods and formats. TRIAL REGISTRATION NUMBER: The study is registered with the Research Registry: researchregistry6697.

Multisystem Inflammatory Syndrome in a Previously Vaccinated Adolescent Female With Sickle Cell Disease.

Multisystem inflammatory syndrome in children (MIS-C) is a serious complication that is observed most commonly in pediatric patients following severe acute respiratory syndrome coronavirus 2 infections. However, the mechanism and predictors of disease are poorly understood. There are no prior reports of MIS-C among patients who have been fully vaccinated, and only a single case of MIS in an adult patient who had received his second shot just 4 days prior to symptom onset. Here, we present an adolescent with sickle cell disease who was fully vaccinated against severe acute respiratory syndrome coronavirus 2 and had no prior history of known or suspected infection, who presented in shock and was ultimately diagnosed with MIS-C. This case highlights the importance of clinical suspicion for MIS-C even when patients are fully vaccinated.

COVID-19 impact on infant and adolescent vaccine supplies.

Vaccine production is quadrupling rapidly, creating supply chain challenges.

Strategic organisational skills predict surgical training success.

INTRODUCTION: Surgical career progression is determined by examination success and Annual Review of Competence Progression (ARCP) outcome, yet data on organisational skills are sparse. This study aimed to determine whether organisational skills related to Core Surgical Training (CST) outcome. Primary outcome measures include operative experience, publications, examination success (Membership of the Royal College of Surgeons or the Diploma in Otolaryngology-Head and Neck Surgery (MRCS/DO-HNS)) and ARCP outcome. METHODS: The study was conducted prospectively at three consecutive CST induction boot camps (2017-2019) providing clinical and simulation training for 125 trainees. Arrival time at course registration was the selected surrogate for organisational skills. Trainees were advised to arrive promptly at 8:45 for registration and that the course would start at 9:00. Trainee arrival times were grouped as follows: early (before 8:45), on time (8:45-8:59am) or late (after 9:00). Arrival times were compared with primary outcome measures. SETTING: Health Education and Improvement Wales' School of Surgery, UK. RESULTS: Median arrival time was 8:53 (range 7:55-10:03), with 29 trainees (23.2%) arriving early, 63 (50.4%) on-time and 33 (26.4%) late. Arrival time was associated with operative experience (early vs late; 206 vs 164 cases, p=0.012), publication (63.2% vs 18.5%, p=0.005), MRCS/DO-HNS success (44.8% vs 15.2%, p=0.029), ARCP outcome (86.2% vs 60.6% Outcome 1, p=0.053), but not National Training Number success (60.0% vs 53.3%, p=0.772). CONCLUSIONS: Better-prepared trainees achieved 25% more operative experience, were four-fold more likely to publish and pass MRCS, which aligned with consistent desirable ARCP outcome. Timely arrival at training events represents a skills-composite of travel planning and is a useful marker of strategic organisational skills.

Trends in inequalities in local authority spending on cultural, environmental and planning services: a longitudinal study in England, Scotland, and Wales

BackgroundLocal authorities (LAs) provide Cultural, Environmental, and Planning (CEP) services, such as parks, libraries, and waste collection, that are vital in supporting the health of the communities they serve. There have been significant changes to LA funding recently, most notably due to the UK government’s austerity programme. These changes have not affected all places equally. To understand potential impacts on health inequalities, we investigated the extent to which areas have been differentially affected by declines in CEP services spending based on local characteristics.MethodsWe conducted a longitudinal ecological study using routinely available data on LA expenditure, as collated in the Place-Based Longitudinal Data Resource. We used generalised estimating equations to determine how expenditure trends varied across 378 LAs in Great Britain between 2009 and 2018 on the basis of country, deprivation, rurality, and local government structure. We investigated the gross expenditure per capita on CEP services, and the CEP expenditure as a proportion of total LA budgets. We conducted analysis using R v4.0.2.ResultsExpenditure per capita for CEP services reduced by 36% between 2009 and 2018. In England, the reduction in per capita spending was steepest in the most deprived quintile of areas, falling by 5.9% [95% CI: 4.7;7.0] per year, compared to 3.3% [95% CI: 2.5;4.1] in the least deprived quintile. Budget cuts in Scotland and Wales have been more equitable, showing little differentiation between most and least deprived areas. Welsh LAs have reduced the proportion of total LA budget spent on CEP services more than any other country (-2.9% per year [95% CI: -4.0;-1.8]), followed by Scotland (-1.5% [95% CI: -2.8;-0.3]) then England (-0.5% [95% CI: -1.0;0.1). In England, rural LAs have reduced their CEP spending share more than those in urban areas, and unitary authorities have reduced their share more than those in a two-tier structure.ConclusionThere have been distinct inequalities in the reduction of spending for CEP services. LAs with a higher baseline level of deprivation, those with a single-tier local government structure, and English rural LAs have been worst affected. These inequalities in cuts to services that impact public health risk widening geographical and social health inequalities. Understanding these inequalities will provide crucial evidence to inform the UK government’s ‘levelling up’ strategy as the country recovers from the COVID-19 pandemic. One limitation of our study is that we were unable to investigate how resources have been distributed within LAs.

Urban rhythms in a small home: COVID-19 as a mechanism of exception.

The amount of living space we have access to is one manifestation of the unequal distribution of housing resources within societies. The COVID-19 pandemic has required most households to spend more time at home, unmasking inequalities and reigniting longstanding debates about the functionality and experience of smaller homes. Drawing on interviews across three UK cities, this article attends to the changing household routines of individuals living in different types of small home, exploring daily life before and during 'lockdown'. Using the concept of urban rhythms, the data show that the lockdown has intensified existing pressures of living in a smaller home - lack of space for different functions and household members - whilst constraining coping strategies, like spending time outside the home. Lockdown restrictions governing mobility and contact acted as a mechanism of exception, disrupting habitual patterns of life and sociability, and forcing people to spend more time in smaller homes that struggled to accommodate different functions, affecting home atmospheres. For some, the loss of normal strategies was so significant that they sought to challenge the new rules governing daily life to protect their wellbeing.

Kenotic Theologies and the Challenge of the 'Anthropocene': From Deep Incarnation to Interspecies Encounter

As the detrimental effects of human agency loom large in the 'Anthropocene', theologians and philosophers have called for restraint by invoking the concept of kenosis. Although a 'self-emptying' form of life helps to counter the ways that humans are increasingly driving other species to extinction, we argue that such calls are often compromised by relying on notions of the Creator's own attenuated or self-limited agency. They therefore trade in a competitive construal that is susceptible to the tendency of human agency to either displace, or project itself upon, all other agencies, inadvertently perpetuating the 'human epoch'. In their place, we critically develop the new direction in kenotic theology that speaks of divine self-realization in history through 'deep incarnation'. Our constructive proposal argues for a more thoroughgoing recognition of both the transcendence of divine agency and, as a corollary, the diverse agencies of our fellow creatures. [ABSTRACT FROM AUTHOR] Copyright of Studies in Christian Ethics is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

How does vulnerability to COVID-19 vary between communities in England? Developing a Small Area Vulnerability Index (SAVI).

BACKGROUND: During the initial wave of the COVID-19 epidemic in England, several population characteristics were associated with increased risk of mortality-including, age, ethnicity, income deprivation, care home residence and housing conditions. In order to target control measures and plan for future waves of the epidemic, public health agencies need to understand how these vulnerabilities are distributed across and clustered within communities. METHODS: We performed a cross-sectional ecological analysis across 6789 small areas in England. We assessed the association between COVID-19 mortality in each area and five vulnerability measures relating to ethnicity, poverty, prevalence of long-term health conditions, living in care homes and living in overcrowded housing. Estimates from multivariable Poisson regression models were used to derive a Small Area Vulnerability Index. RESULTS: Four vulnerability measures were independently associated with age-adjusted COVID-19 mortality. Each SD increase in the proportion of the population (1) living in care homes, (2) admitted to hospital in the past 5 years for a long-term health condition, (3) from an ethnic minority background and (4) living in overcrowded housing was associated with a 28%, 19% 8% and 11% increase in age-adjusted COVID-19 mortality rate, respectively. CONCLUSION: Vulnerability to COVID-19 was noticeably higher in the North West, West Midlands and North East regions, with high levels of vulnerability clustered in some communities. Our analysis indicates the communities who will be most at risk from a second wave of the pandemic.