Photoactive amphiphiles for the assembly of supramolecular architectures.

The presented study reports the use of photoactive templating structures for the design of porous frameworks with built-in optical functionalities. The materials have been synthesised and characterised using powder X-ray diffractometry, UV-visible absorption and emission spectroscopy. The latter shows that, by varying the relative amount of an amphiphilic chromophore in the micellar templates, it is possible to tune the light absorption and emission properties over the visible spectrum, by means of controlling the molecular organisation and the excitonic coupling of aggregated species. This enables versatile solid materials that can be used as optical components for light-harvesting and converting systems to be obtained .

The hospital standardised mortality ratio: a powerful tool for Dutch hospitals to assess their quality of care?

AIM OF THE STUDY: To use the hospital standardised mortality ratio (HSMR), as a tool for Dutch hospitals to analyse their death rates by comparing their risk-adjusted mortality with the national average. METHOD: The method uses routine administrative databases that are available nationally in The Netherlands--the National Medical Registration dataset for the years 2005-2007. Diagnostic groups that led to 80% of hospital deaths were included in the analysis. The method adjusts for a number of case-mix factors per diagnostic group determined through a logistic regression modelling process. RESULTS: In The Netherlands, the case-mix factors are primary diagnosis, age, sex, urgency of admission, length of stay, comorbidity (Charlson Index), social deprivation, source of referral and month of admission. The Dutch HSMR model performs well at predicting a patient's risk of death as measured by a c statistic of the receiver operating characteristic curve of 0.91. The ratio of the HSMR of the Dutch hospital with the highest value in 2005-2007 is 2.3 times the HSMR of the hospital with the lowest value. DISCUSSION: Overall hospital HSMRs and mortality at individual diagnostic group level can be monitored using statistical process control charts to give an early warning of possible problems with quality of care. The use of routine data in a standardised and robust model can be of value as a starting point for improvement of Dutch hospital outcomes. HSMRs have been calculated for several other countries.

Tuberculosis transmission and the impact of intervention on the incidence of infection.

SETTING: England and Wales. OBJECTIVE: To quantify the relative contribution of vaccination, chemotherapy and preventive therapy to the reduction in tuberculosis incidence in England and Wales between 1953 and 1990. DESIGN: A compartmental model of tuberculosis transmission was fitted to notification data between 1913 and 1939 to estimate pre-vaccination parameters. Best-fit estimates of the rates of chemotherapy and preventive therapy were derived by fitting the model to notification data between 1953 and 1990. Published vaccination rates were used. MAIN OUTCOME MEASURE: Number of cases of pulmonary tuberculosis averted. RESULTS: The numbers of respiratory tuberculosis cases averted between 1953 and 1990 by the use of preventive therapy, vaccination and chemotherapy were 288318, 57085 and 206996, respectively. CONCLUSIONS: Of those interventions considered, preventive therapy has the greatest impact on transmission. The duration of infectiousness is long, with an onset that is likely to pre-date sputum positivity.

Rationale for the new GP deprivation payment scheme in England: effects of moving from electoral ward to enumeration district underprivileged area scores.

BACKGROUND: The Department of Health introduced a new deprivation payments system for general practitioners (GPs) on 1 April 1999. Following a three-year phasing-in process, registered patients will attract deprivation payments based on the underprivileged area (UPA) score of their enumeration district (ED) of residence, rather than their electoral ward, changing the pattern and distribution of payments throughout England. AIM: To assess the rationale behind the changed deprivation payments system for GPs in England and to examine its impact on GP and practice payments. DESIGN OF STUDY: A quantitative study modelling practice-based deprivation payments. SETTING: A total of 25,450 unrestricted principal GPs in 8919 practices in England. METHOD: The effect of three new components in the system were examined: changes in the ED score ranges attracting payment, the percentage increase in the size of successive payment bands, and the total budget. The relationship between consultation rates (used as a proxy for workload) and UPA score was examined, together with changes in GP payments calculated nationally and by geographical area. RESULTS: A total of 11.6% of the population of England live in wards with a UPA score of 30 or more, qualifying for deprivation payments, and a similar proportion (11.4%) live in EDs with a UPA score of 20 or more. The larger percentage increases in the size of payments in successive ED UPA bands is supported by the modelled relationship between consultation rate and UPA score. Financially, under the new deprivations payment system, entitlement widens with 88% of practices receiving a payment. Overall, 74% of GPs gain and 13% lose (3% losing more than 1500 Pounds), with 13% receiving no payment. CONCLUSION: The new ED system maps onto the previous system well. Moreover, it more finely discriminates between smaller areas of different relative deprivation and, thereby, targets payments more accurately.

Predicting admission rates to secure forensic psychiatry services.

BACKGROUND: The planning and development of secure forensic psychiatry services for mentally disordered offenders in England and Wales has proceeded independently within different regional areas. However, certain mental disorders, offenders, and offending behaviour are all more prevalent in geographical areas characterized by socio-economic deprivation and social disorganization. Failure to consider these factors has led to inadequate service provision in some areas and inequity in funding. A new model is required to predict admissions to these services as an aid to resource allocation. METHOD: Actual admissions (N = 3155) to high and medium secure psychiatric services for seven of 14 (pre-reorganization) Regional Health Authorities, 1988-94. Expected admissions were calculated for each district using 1991 census data adjusted for under-enumeration. Standardized psychiatric admission ratios were calculated and a range of social, health status, and service provision data were used as explanatory variables in a regression analysis to determine variation between districts. RESULTS: Actual psychiatric admissions varied from 160% above to 62% below expected for age, sex, and marital status, according to patients' catchment area of origin, measured according to deciles of the distribution of underprivileged area scores at ward level. The most powerful explanatory variables included a composite measure of social deprivation, ethnicity and availability of low secure beds at regional level. CONCLUSION: Admission rates to secure forensic psychiatry services demonstrate a linear correlation with measures of socio-economic deprivation in patients catchment area of origin. A model was developed to predict admissions from District Health Authorities and is recommended for future use in resource allocation. Identification of factors that explain higher admission rates of serious offenders with mental disorder from deprived areas is a priority for future research.

A study of the variation in tuberculosis incidence and possible influential variables in Manchester, Liverpool, Birmingham and Cardiff in 1991-1995.

SETTING AND OBJECTIVE: The reversal of the decline in United Kingdom tuberculosis rates has sparked a resurgence of interest in the epidemiology and prevention of tuberculosis in the UK. In this paper we quantify the primary factors explaining the variability in the electoral ward level relative risk of tuberculosis in Manchester, Liverpool, Birmingham and Cardiff. DESIGN: Ecological analysis of the incidence of tuberculosis in 397 wards using hospital admissions data as a proxy for tuberculosis incidence. Admissions were evaluated from the financial years 1991/1992 to 1994/1995. Ward level covariates included measures of country of birth, ethnicity and various socio-economic measures. RESULTS: Separate analyses were carried out for pulmonary and non-pulmonary tuberculosis. For pulmonary tuberculosis the final model included measures of the ward population born in India and Pakistan, overcrowded housing and not-owner-occupied housing. For non-pulmonary tuberculosis the covariates were ward population born in India and Pakistan, overcrowded housing and the proportion of households with no car. CONCLUSIONS: The country of birth of the ward population is the single most influential explanatory factor in the variability of the ward rates for both pulmonary and non-pulmonary tuberculosis in these four cities. Measures of poverty are of secondary importance.

Medium secure forensic psychiatry services: comparison of seven English health regions.

BACKGROUND: Regional medium secure developments have proceeded unevenly, with wide variations in resources to deliver services. AIMS: To compare patients admitted to seven (pre-reorganisation) regional services and styles of service delivery. METHOD: A record survey of a complete sample of 2608 patients admitted on 3403 occasions between 1 January 1988 and 31 December 1994. RESULTS: Services differed according to location of patients before admission, their legal basis for detention, criminal and antisocial behaviour, diagnosis, security needs and length of stay. Regions with more resources and lower demand provided a wider range of services. Thames services were relatively under-provided during the study period, with North East Thames substantially reliant on admissions to private hospitals. CONCLUSIONS: Uncoordinated development led to under-provision despite high demand. Certain regions prioritised offender patients and did not support local psychiatric services. New standards are required for service specification and resource allocation to redress inequality. Traditional performance measures were of limited usefulness in comparing services.

Ethnic differences in admissions to secure forensic psychiatry services.

BACKGROUND: Persons of African-Caribbean origin are more frequently imprisoned, and increasing evidence suggests they are detained more frequently in psychiatric hospitals, following offending behaviour. AIMS: To estimate population-based prevalence rates of treated mental disorder in different ethnic groups compulsorily admitted to secure forensic psychiatry services. METHOD: A survey was recorded of 3155 first admissions, from 1988 to 1994, from half of England and Wales, with 1991 census data as the denominator adjusted for under-enumeration. RESULTS: Compulsory admissions for Black males were 5.6 (CI 5.1-6.3) times as high as, and for Asian males were half, those for White males; for Black females, 2.9 (CI 2.4-4.6) times as high and for Asian females one-third of those for White females. Admissions of non-Whites rose over the study period. Patterns of offending and diagnoses differed between ethnic groups. CONCLUSIONS: Variations in compulsory hospitalisation cannot be entirely attributed to racial bias. Community-based services may be less effective in preventing escalating criminal and dangerous behaviour associated with mental illness in African-Caribbeans.

The quality of care in hospitals.

In recent years there has been an increase in the regulation of the medical profession. In the past there have been problems. The GMC can act only when things go seriously wrong. It has, however, introduced the health and performance procedures, increased the proportion of lay members, is working on revalidation and has introduced Good Medical Practice which makes very clear what is expected of a doctor and will be relevant to doctors' contracts. The medical Royal Colleges can be influential in raising general standards but the activities of the different colleges are not well co-ordinated and they cannot compel doctors to take part in continuing medical education, although this is an aim. Without statutory powers to introduce changes they have to carry their members with them. Audit has its problems and these are understandable because of the natural defensiveness which can occur if there is a threat of possible litigation. The Department of Health has had no proper system for measuring the quality of the care for which it is responsible and largely sees this as the responsibility of individual doctors. Responsibility for the quality of care is shared in a confusing way between different groups. But there is change in the air. There are moves for a 'patient led NHS'. The Government has a new emphasis on quality of care, there is greater sophistication in the methods used for surveying patients' experiences. Measurement of hard outcome data such as adjusted death rates can reveal underlying system failures. Finally, there is a growing realisation that within medicine, as within other complex organisations, doctors are not perfect and will always make errors. Blaming individuals will not in itself make much contribution to the improvement of the overall system: we have to work towards ways of reducing system failures.

Explaining differences in English hospital death rates using routinely collected data.

OBJECTIVES: To ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios. DESIGN: Weighted linear regression analysis of routinely collected data over four years, with hospital standardised mortality ratios as the dependent variable. SETTING: England. SUBJECTS: Eight million discharges from NHS hospitals when the primary diagnosis was one of the diagnoses accounting for 80% of inpatient deaths. MAIN OUTCOME MEASURES: Hospital standardised mortality ratios and predictors of variations in these ratios. RESULTS: The four year crude death rates varied across hospitals from 3.4% to 13.6% (average for England 8.5%), and standardised hospital mortality ratios ranged from 53 to 137 (average for England 100). The percentage of cases that were emergency admissions (60% of total hospital admissions) was the best predictor of this variation in mortality, with the ratio of hospital doctors to beds and general practitioners to head of population the next best predictors. When analyses were restricted to emergency admissions (which covered 93% of all patient deaths analysed) number of doctors per bed was the best predictor. CONCLUSION: Analysis of hospital episode statistics reveals wide variation in standardised hospital mortality ratios in England. The percentage of total admissions classified as emergencies is the most powerful predictor of variation in mortality. The ratios of doctors to head of population served, both in hospital and in general practice, seem to be critical determinants of standardised hospital death rates; the higher these ratios, the lower the death rates in both cases.

Adenosquamous carcinoma of the pancreas.

HYPOTHESIS: Adenosquamous carcinoma of the pancreas is a rare but particularly virulent variant of invasive ductal carcinoma. This review will demonstrate the aggressive biologic activity, histopathologic features, and DNA flow cytometric characteristics of this aggressive lesion. In addition, the outcome is less favorable than in other pancreatic neoplasms, in spite of aggressive surgical and postoperative adjuvant therapy. DESIGN: A retrospective review of 6 patients treated during an 8-year period. SETTING: A major urban university tertiary referral hospital. PATIENTS: There were 6 patients with this unusual tumor seen between 1990 and 1998. There were 4 men and 2 women, all white, with a mean+/-SD age of 63.5+/-14.7 years. Symptoms were similar to those in patients with more common pancreatic malignant neoplasms. RESULTS: Four patients with tumors in the head of the pancreas had pancreatoduodenectomy, and 2 with body and or tail lesions had distal pancreatectomy and splenectomy. Pathologically, all the tumors were poorly differentiated and aneuploid, and 5 of the 6 were locally metastatic. All but 1 patient had postoperative complications, but there were no operative deaths. One half of the patients received postoperative adjuvant chemotherapy and radiation therapy. Only 1 patient is still alive at 9 months after surgery, but has known residual cancer around his portal vein noted during palliative distal pancreatectomy. CONCLUSIONS: Adenosquamous carcinoma of the pancreas is an uncommon variant of exocrine pancreatic neoplasm. It is characterized by an admixture of adenomatous and squamous cell elements and demonstrates aggressive biologic behavior. This series of 6 patients is similar to the 134 cases reported since 1907, in that survival is short despite aggressive surgical therapy. Few patients with this disease live more than 1 year. Aggressive therapy should be tempered by the realization of the uniform poor prognosis associated with this malignant neoplasm.

Do social factors affect where patients die: an analysis of 10 years of cancer deaths in England.

BACKGROUND: This study investigated whether indices of social deprivation were related to the proportion of cancer patients who died at home. METHODS: Data were derived from death registrations for all cancer deaths 1985-1994 in England. Two indices of deprivation (Underprivileged Area Score (UPA), or Jarman, and Townsend scores) were calculated for each electoral ward; 1991 Census data were used. The scores use combinations of variables, including the percentage in overcrowded homes, the percentage of elderly people living alone, the percentage of one-parent families, etc. A high score indicates more deprivation. The main outcome measures were the proportion (in five and ten year averages) of cancer deaths which occurred at home, calculated for every electoral ward (with populations usually ranging from 5000 to 11,000). Spearman rho was used to test for correlations between the proportion of cancer deaths at home and deprivation score. Electoral wards were categorized by deprivation score into three groups of equal size and analysed over 10 years. Multivariate analysis was used to determine the relative association of different patient based and electoral ward variables with cancer death at home. p < 0.05 (two-tailed) was taken as significant. RESULTS: There were over 1.3 million death registrations from cancer in the 10 years. The proportion who died at home was 0.27, in hospital 0.47, and other setting 0.26. There were wide variations (0.05-0.75) in the proportion of people who died at home in different electoral wards. Small inverse correlations were found between the percentage who died at home and the UPA (-0.35; p < 0.001) and Townsend (-0.26; p < 0.001) scores. The correlations were greatest in North Thames (-0.63, UPA) and smallest in West Midlands (-0.20, UPA). The proportion of home deaths for the different bands of deprivation were: 0.30 (low deprivation), 0.27 (middle deprivation) and 0.24 (high deprivation). Plotting the trends over 10 years suggests no change in this relationship. Multiple regression analysis predicted several ward and patient characteristics and accounted for 30 per cent of the variation. Increased age (patient variable), Jarman score and ethnic minorities (both ward variables) were associated with fewer patients dying at home. Being male and having cancer of the digestive organs were associated with home death. CONCLUSION: There are wide variations in the percentage of cancer deaths at home in different electoral wards. Social factors are inversely correlated with home cancer death, and may explain part of this variation. Home care in deprived areas may be especially difficult to achieve.

Patients with personality disorder admitted to secure forensic psychiatry services.

BACKGROUND: Treatment of patients with personality disorder remains controversial and severe mental illness is prioritized in secure forensic psychiatry services. AIMS: To compare patients with personality disorder and mental illness according to demography, referral, criminality, previous institutionalisation and diagnostic comorbidity. METHOD: A record survey of 511 patients with personality disorder and 2575 with mental illness admitted to secure forensic psychiatry services between 1 January 1988 and 31 December 1994 from half of England and Wales. RESULTS: Personality disorder admissions declined over time; more were female, White, younger and extensively criminal (specifically, sexual and arson offences). Personality disorder was highly comorbid; antisocial, borderline, paranoid and dependent personality disorder were most prevalent. CONCLUSIONS: Patients with personality disorder were highly selected and previously known to psychiatric services. Referrer, diagnostic comorbidity and behavioural presentation determined their pathways into care. Future research must determine whether their continuing admission represents effective use of scarce resources and whether new services are required.

The Swedish UPA score: an administrative tool for identification of underprivileged areas.

The purpose was to construct a Swedish social deprivation index analogous to the underprivileged area (UPA) score, used in the UK to distribute resources to general practice for patients resident in the most underprivileged areas. UPA scores were calculated using 1990 Swedish census data and the 1992 unemployment and migration registers for all 8,502 SAMS (small area market statistics) areas with more than 50 inhabitants. Selection of the eight variables included in the score and weights attached to each were derived from a national survey of general practitioners in the UK representing the degree to which they considered that each factor increased their workload or pressure on services. The UPA score for each area is the sum of the eight normalised (arc sin square root), standardised (z scores) and weighted variables for that area. The distribution of UPA scores ranged from -79.13, in the most affluent areas to 46.10 in the most underprivileged areas. It was found that a wide range of social deprivation exists at small area level.