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Background: The number of urgent referrals from primary care to specialist one stop breast clinics continues to rise beyond the capacity of the 2-week wait service. This study aims to use artificial intelligence (AI) to identify patients with new breast symptoms requiring a biopsy to identify those who should be prioritised for urgent breast clinic assessment. Methods: Data were collected retrospectively for patients attending one stop triple assessment breast clinic at Broomfield hospital between 1 June and 1 October 2021. PHP machine learning software was used to run AI on the data to identify patients who had a core biopsy in clinic. Results: A total of 794 cases were referred to one stop breast clinic for new breast symptoms-37 male (4.6%) and 757 female (95.3%). The average age of the patients included was 43.2 years. Five hundred thirty-six patients (67.5%) presented with a breast lump, 180 (22.7%) with breast pain, 61 (7.7%) with changes to shape or skin and 13 (1.6%) with a lump identified by their general practitioner. The patients who had a biopsy were of increased age [52.8 (SD 17.9) vs. 44.1 (SD 16.8), P<0.001], and had previous mammogram [n=21, (31.8%) vs. n=148 (20.3%), P 0.03], previous benign breast disease [n=9 (13.6%) vs. n=23 (3.1%), P<0.001], and increased use of HRT [n=13 (19.7%) vs. n=53 (6.4%), P<0.001]. The sensitivity and specificity of AI with neural network algorithms were 84% and 90%, respectively. Conclusion: AI was very effective at predicting the presenting symptoms that are likely to result in biopsy and can therefore be used to identify patients who need to be seen urgently in breast clinic.

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Introduction: Increasing evidence suggests that de-escalation of axillary surgery is safe, without significantly impacting patient outcome. Obtaining positive lymph nodes at a sentinel lymph node biopsy (SNB) can guide decisions toward the requirement of axillary nodal clearance (ANC). However, methods to predict how many further nodes will be positive are not available. This study investigates the feasibility of predicting the likelihood of a negative ANC based on the ratio between positive nodes and the total number of lymph nodes excised at SNB. Methods: Retrospective data from January 2017 to March 2022 was collected from electronic medical records. Patients with oestrogen receptor (ER) positive and HER2 negative receptor disease were included in the study. ER-negative and HER2-positive disease was excluded, alongside patients who had chemotherapy before ANC. Results: Of 102 patients, 58.8% (n=60) had no macrometastasis at ANC. On average, 2.76 lymph nodes were removed at SNB. A higher SNB ratio of positive to total nodes [OR 11.09 (CI 95% 2.33-52.72), P=0.002] had a significant association with positive nodes during ANC. SNB ratio less than or equal to 0.33 (1/3) had a specificity of 79.2% in identifying cases that later had a negative completion ANC, with a 95.8% specificity of no further upgrade of nodal staging. Conclusion: A low SNB ratio of less than 0.33 (1/3) has a high specificity in excluding the upgradation of nodal staging on completion of ANC, with a false-negative rate of less than 5%. This may be used to identify patients with a low risk of axillary metastasis, who can avoid ANC.

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The hydrophobicity of silica and composite aerogels has enabled them to acquire applications in a variety of fields. With remarkable structural, morphological, and physiochemical properties such as high porosity, surface area, chemical stability, and selectivity, these materials have gained much attention of researchers worldwide. Moreover, the hydrophobic conduct has enabled these aerogels to adsorb substances, i.e., organic pollutants, without collapsing the pore and network structure. Hence, considering such phenomenal properties and great adsorption potential, exploiting these materials for environmental and biomedical applications is trending. The present study explores the most recent advances in synthetic approaches and resulting properties of hydrophobic silica and composite aerogels. It presents the various precursors and co-precursors used for hydrophobization and gives a comparative analysis of drying methods. Moreover, as a major focus, the work presents the recent progress where these materials have shown promising results for various environmental remediation and biomedical applications. Finally, the bottlenecks in synthesis and applicability along with future prospects are given in conclusions.

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BACKGROUND: The study aimed to assess the effect of oral prophylactic antibiotics (OAB) with mechanical bowel preparation (MBP) on the serial measurement of postoperative inflammatory markers and clinical outcomes of the patients undergoing laparoscopic colorectal cancer resection surgery. METHODS: A retrospective and prospective data collection was carried out from January 2019 to March 2020 for the patients undergoing laparoscopic colorectal cancer resection. Daily measurements of inflammatory markers were obtained up to 7 days following surgery. The measurements of inflammatory markers were compared between patients who received a 1 week course of OAB along with MBP to those who only received MBP. RESULTS: There were a total of 110 patients that were divided into 2 groups: patients who received OAB and MBP (n = 44, 40%) and those who had MBP only (n = 66, 60%). There was no significant difference between the patient characteristics and preoperative staging of the cancer between the 2 groups. The overall length of stay was significantly lower in the patients who received OAB (9.09 days [SD 7.94] vs. 6.63 days [SD 4.96], P 0.02). The patients with OAB and MAP had persistently and significantly low levels of white blood cell count, CRP, and neutrophil count throughout the postoperative period as compared to those who only had MBP. CONCLUSION: The study demonstrated reduction in serial measurement of inflammatory markers throughout postoperative stay for the patients receiving preoperative OAB. The use of OAB helps in physiological recovery of the patient by reducing the inflammatory process postoperatively.

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Importance: Total thyroidectomy is associated with risks related to temporary hypocalcemia and vocal quality dysfunction. Dexamethasone has been proposed to have a physiological effect on hypocalcemia and voice quality. Objective: To assess the effect of preoperative dexamethasone used to improve hypocalcemia and postthyroidectomy voice dysfunction. Design, Setting, and Participants: This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted from January 15, 2014, to December 31, 2019, at the Department of Surgery, Holy Family Hospital in Rawalpindi, Pakistan. All patients with a benign thyroid condition and no preoperative corrected hypocalcemia and voice or vocal quality dysfunction were included. Patients were excluded if they had previous thyroid or neck surgery, known vocal cord dysfunction on laryngoscopy, hearing or voice problems, a history of gastroesophageal reflux, stomach ulcer disease, or contraindications to steroid use. Interventions: Corrected serum calcium levels and Voice Analog Score defined and measured preoperatively. The dexamethasone group received a 2-mL intravenous dose of 8 mg of dexamethasone 60 minutes before the induction of anesthesia. In contrast, the placebo group received 2 mL of intravenous normal saline (0.9%) 60 minutes before the induction of anesthesia. Main Outcomes and Measures: Evidence of hypocalcemia and voice dysfunction. Voice dysfunction was defined as a subjective score of less than 50 on a Voice Analog Score scale of 0 to 100 points. Results: A total of 192 patients (mean [SD] age, 38.9 [12.4] years; 156 women [81.2%]) were included in the study, with 96 patients randomized to each study group (dexamethasone group, mean [SD] age, 39.2 [12.1] years; 75 women [78.1%]; placebo group, mean [SD] age, 38.5 [12.9] years; 81 women [84.5%]). In the first 24 hours after undergoing thyroidectomy, 47 patients (24.4%) developed hypocalcemia and 18 (9.4%) were symptomatic. At 3 days postthyroidectomy, 4 of 96 patients (4.2%) in the placebo group had hypocalcemia compared with no patients in the dexamethasone group. At 24 hours postthyroidectomy, 8 of 96 patients (8.3%) in the dexamethasone group had voice dysfunction compared with 32 of 96 patients (33.3%) in the placebo group. A total of 40 patients (20.8%) reported voice dysfunction. The absolute reduction in the rate of hypocalcemia at 24 hours was 24% (95% CI, 11.9%-35.2%) and at 3 days was 4.2% (-0.44% to 10.0%). The rate of symptomatic hypocalcemia was 19% lower in the dexamethasone group than in the placebo group (95% CI, 11.1%-27.7%). The rate of voice dysfunction was 25% lower in the dexamethasone group than in the placebo group (95% CI, 13.7%-35.7%). Conclusions and Relevance: In this randomized clinical trial, a single preoperative dose of dexamethasone was safe and effective in reducing postoperative hypocalcemia and voice dysfunction rates in patients undergoing thyroidectomy. Trial Registration: ClinicalTrials.gov identifier: NCT04752852.

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INTRODUCTION: The study aimed to devise a self-referral mobile/web application for patients with new breast symptoms, giving them an outcome, thus bypassing the need for primary care consultation. METHODS: The online application was designed on the automated algorithm based on evidence-based guidelines for referral to breast onco-plastic units. A retrospective questionnaire-based anonymous survey was carried out at the breast unit in Southend University Hospital (January 2019 to March 2020). The outcome of the patients was recorded, the same data was entered in the software and its outcome was compared with their clinic outcome to assess and validate the software. Chi-square and t-test were used in formulating results. RESULTS: Data was collected for 366 patients who were referred urgently to the clinic. Only 50.5% (n = 186) were appropriately referred, with the main complaint being breast lump (94.1%). 39.6% of referred patients did not require a secondary care referral. Sensitivity and specificity for identifying patients requiring urgent referral was 100% and 98%, respectively. CONCLUSION: A significant number of urgent referrals to breast units do not require urgent specialist referral, and this results in a big strain on the hospital service. The discussed self-referral pathway is a promising alternative with the potential to reduce workload in primary and secondary care and improve patient satisfaction.

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Introduction The study aimed to assess the accuracy of online software in the use of self-referral to breast surgery clinics for patients with new signs and symptoms. The study also evaluated the appropriateness of GP referrals to breast clinics and evaluated patients' perceptions of an online self-referral portal to the breast clinic for the assessment of breast signs and symptoms.  Design and methods The pilot study was divided into two phases. In the first phase, prospective questionnaire-based data was collected from patients who were referred by a GP and presented to the regional breast unit with new signs and symptoms for breast conditions, Princess Alexandra Hospital NHS Trust (May - October 2018). The questionnaire assessed the time at each stage required by the patient to have a visit at the breast unit. It also asked the patient's opinion about an online self-referral portal to the surgical clinic. They were given hypothetical scenarios to evaluate their understanding of breast conditions. In the second phase, the patients presenting to symptomatic breast clinics were provided with the iPad to fill in their medical information in the online software. The data was collected between July and October 2019. The software algorithm was based on the National Institute of Clinical Health and Excellence (NICE) guidelines for breast conditions (2015). Breast surgeons' recommendations acted as a standard to evaluate the accuracy of GPs' referrals and software outcome for each patient.  Results There were 80 patients (mean age 49.1 [SD: 17.7], all females) included in the first phase of the study. The most common clinical presentation was a breast lump (47.6%), followed by breast pain (26.9%) and nipple changes (7.9%). Breast surgeons considered appropriate 75.6% of the referrals made by the GP. Seventy-two percent of the patients got an urgent appointment to see their GP, and 94.8% of the patients were urgently referred by their GP to see the breast surgeon. Only 37.8% of the urgent referrals were correctly referred as urgent. Having a direct online referral system for breast conditions will be beneficial for patients was agreed by 78.4%. The majority (98.1%) of the participants answered correctly for the hypothetical questions requiring breast surgeon review. In the second phase, there were a total of 86 patients with a mean age of 43.9 (SD: 13.3). The most common presentation was breast lump (n=68, 79.1%) and other presentations included breast pain, nipple changes, and discharge. The GPs' accuracy of correct referral was 69.1%. One third (30.9%) of the referrals could have been managed in the community or as a routine review by the breast surgeon. In comparison, the online software's accuracy was 85.1% accurate (p=0.001). The accuracy for detecting patients who needed urgent breast clinic review was 100% for online software.  Conclusion A large proportion of referrals could have been dealt with in the community or referred routinely. Patients would prefer a direct online referral system to the breast clinic. They understand red flag signs and symptoms. Online software has the potential to streamline patients for symptomatic breast clinics. It can reduce the burden on the GPs who are constantly under pressure to diagnose patients accurately and refer to the correct specialty appropriately within a short time.

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INTRODUCTION: COVID-19 pandemic has resulted in a strong impact on students' wellbeing, with associated uncertainty about the future. We conducted a cross-sectional survey to assess the psychological effects of COVID-19 on the medical education of final year students in Pakistan. METHODS: We conducted prospective, cross-sectional survey, as a snapshot, from June 07, 2020 till June 16, 2020, among final year medical and dental students. The 20-questions survey questionnaire was based on rating-scale items to focus on psychological symptoms, institutional preparedness for such crisis and confidence in becoming a future doctor. Descriptive statistics were calculated using Multivariate regression analysis. RESULTS: Majority of participants (n = 1753/2661, 65.9%) were female. Despite timely closure of institutes, delay in the start of the online teaching (beta coefficient 0.08, P-value 0.02) was significantly correlated with the depressive symptoms. A significant percentage of students (n = 1594, 59.9%) wanted a delay in exit exams due to intimidation. A similar proportion of students also lost confidence to be a competent doctor in future which was positively associated with male gender (beta coefficient 0.21, P-value < 0.001). CONCLUSION: Our study shows that COVID-19 pandemic has brought significant psychological influence on the medical education of final year students. Despite a stressful crisis, final year medical and dental students are still willing to serve the community. In addition to supporting their emotions and psychological wellbeing, stress counselling, and transforming current medical curricula is crucial to pursue ceaseless medical education and to become a safe future doctor.

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BACKGROUND: Abdominal aortic graft infections are a major complication following abdominal aortic aneurysm surgery, with high morbidity and mortality rates. They can be treated surgically or conservatively using medical management. The two most common surgical techniques are in situ replacement of the graft and extra-anatomical bypass. Medical management most commonly consists of a course of long-term antibiotics. There is currently no consensus on which intervention (extra-anatomical bypass, in situ replacement, or medical) is the most effective in managing abdominal aortic graft infections. Whilst in emergency or complex situations such as graft rupture surgical management is the only option, in non-emergency situations it is often personal preference that influences the clinician's decision-making. OBJECTIVES: To assess and compare the effects of surgical and medical interventions for abdominal aortic graft infections. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and WHO ICTRP and ClinicalTrials.gov trials registers to 2 December 2019. We also reviewed the bibliographies of the studies identified by the search and contacted specialists in the field and study authors to request information on any possible unpublished data. SELECTION CRITERIA: We aimed to include all randomised controlled trials that used surgical or medical interventions to treat abdominal aortic graft infections. The definitions of abdominal aortic graft infections were accepted as presented in the individual studies, and included secondary infection due to aortoenteric fistula. We excluded studies presenting data on prosthetic graft infections in general, unless data specific to abdominal aortic graft infections could be isolated. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all studies identified by the search. We planned to independently assess risk of bias of the included trials and to evaluate the quality of the evidence using the GRADE approach. Our main outcomes were overall mortality, amputation, graft re-infection, overall graft-related complications, graft-related mortality, acute limb ischaemia, and re-intervention. MAIN RESULTS: We identified no randomised controlled trials to conduct meta-analysis. AUTHORS' CONCLUSIONS: There is currently insufficient evidence to draw conclusions to support any treatment over the other. Multicentre clinical trials are required to compare different treatments for the condition.

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Red palm weevil (Rhynchophorus ferrugineus) is a voracious pest of date palm worldwide. Pakistan ranks sixth in date palm production globally. Losses to date palm plantations in Pakistan sometimes surpass 10%-20%. Most of the traditional management strategies used by farmers have been found insignificant to combat this voracious pest. The entomopathogenic fungi, Beauveria bassiana [QA-3(L) and QA-3(H)] and insecticides, Nitenpyram (Active 10% SL) [NIT (L) and NIT (H)] were applied to larval (2nd, 4th, and 6th), pupal and adult stages of R. ferrugienus. Integration or alone application of fungi with insecticides at different concentration under laboratory conditions. Combined application was depicted additive and synergistic interactions. Contrarily, highest cumulative mortality (100%) was recorded in 2nd instar larvae as compared to later instar larvae at combined application. The maximum pupal and adult mortality remained 89% and 66% respectively after treatment with [QA-3 (H) + NIT (L)]. The combination of B. bassiana at higher concentration whereas Nitenpyram at lower dose was found more lethal to larvae, pupae and adults of R. ferrugineus. This signifies the need of combining B. bassiana and bio-rational insecticides that can reduce the cost of management with least harm to environment and natural enemies.

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BACKGROUND: We aimed to compare the characteristics and types of heart failure (HF) patients termed "high-impact users", with high long-term readmission rates, in different regions in England. This will allow clinical factors to be identified in areas with potentially poor quality of care. METHODS: Patients with a primary diagnosis of heart failure (HF) in the period 2008-2009 were identified using nationally representative primary care data linked to national hospital data and followed up for 5 years. Group-based trajectory models and sequence analysis were applied to their readmissions. RESULTS: In each of the 8 NHS England regions, multiple discrete groups were identified. All the regions had high-impact users. The group with an initially high readmission rate followed by a rapid decline in the rate ranged from 2.5 to 11.3% across the regions. The group with constantly high readmission rate compared with other groups ranged from 1.9 to 12.1%. Covariates that were commonly found to have an association with high-impact users among most of the regions were chronic respiratory disease, chronic renal disease, stroke, anaemia, mood disorder, and cardiac arrhythmia. Respiratory tract infection, urinary infection, cardiopulmonary signs and symptoms and exacerbation of heart failure were common causes in the sequences of readmissions among high-impact users in all regions. CONCLUSION: There is regional variation in England in readmission and mortality rates and in the proportions of HF patients who are high-impact users.

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INTRODUCTION: The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate. RESULTS: Based on the trends in readmission rates, GBTM classified elective AAA repair (n=16,973) patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex (P=0.001) undergoing other vascular procedures (P=0.003), poor socioeconomic status index (P < 0.001), older age (P < 0.001), and higher comorbidity score (P < 0.001). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair (n=4144) had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (P < 0.001), heart failure (P = 0.01), peripheral vascular disease (P < 0.001), female sex (P = 0.02), open repair (P < 0.001), and undergoing other related procedures (P=0.05). The AUC for c-statistics was 0.71. CONCLUSION: Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbidities perioperatively and during their follow-up.

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INTRODUCTION: The aim of the study was to examine common sequences of causes of readmissions among those patients with multiple hospital admissions, high-impact users, after abdominal aortic aneurysm (AAA) repair and to focus on strategies to reduce long-term readmission rate. METHODS: The patient cohort (2006-2009) included patients from Hospital Episodes Statistics, the national administrative data of all NHS English hospitals, and followed up for 5 years. Group-based trajectory modelling and sequence analysis were performed on the data. RESULTS: From a total of 16,973 elective AAA repair patients, 18% (n=3055) were high-impact users. The high-impact users among ruptured abdominal aortic aneurysm (rAAA) repair constituted 17.3% of the patient population (n=4144). There were 2 subtypes of high-impact users, short-term (7.2%) with initial high readmission rate following by rapid decline and chronic high-impact (10.1%) with persistently high readmission rate. Common causes of readmissions following elective AAA repair were respiratory tract infection (7.3%), aortic graft complications (6.0%), unspecified chest pain (5.8%), and gastrointestinal haemorrhage (4.8%). However, high-impact users included significantly increased number of patients with multiple readmissions and distinct sequences of readmissions mainly consisting of COPD (4.7%), respiratory tract infection (4.7%), and ischaemic heart disease (3.3%). CONCLUSION: A significant number of patients were high-impact users after AAA repair. They had a common and distinct sequence of causes of readmissions following AAA repair, mainly consisting of cardiopulmonary conditions and aortic graft complications. The common causes of long-term mortality were not related to AAA repair. The quality of care can be improved by identifying these patients early and focusing on prevention of cardiopulmonary diseases in the community.

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Aims: We aimed to identify subgroups in the patient population with different trajectories of long-term readmission rates. The study also aimed to assess common causes and their sequences of readmissions for each subgroup. Methods and results: Patients with a primary diagnosis of heart failure (HF) in the period 2008-09 were identified using nationally representative primary care data linked to national hospital data, which contain information on 10.5 million patients. Heart failure patients were followed up for 5 years. Group-based trajectory models and sequence analysis were applied. The model categorised the HF population (n = 9466) into five subgroups: low-impact (66.9%); two intermediate ones (27.4%); chronic high-impact (2.3%) with steady high annual readmission rates; and short-term high-impact (3.4%) with rapid decline in readmission rates. The groups were defined by their trends of yearly number of readmissions. The all-cause 5-year mortality was highest in the short-term high-impact group (n = 185, 72.8%), followed by Group 2 (intermediate users) (n = 744, 58.8%), low-impact (n = 4244, 56.9%), chronic high-impact (n = 88, 37.6%), and Group 1 (intermediate users) (n = 401, 30.3%) (P < 0.01). Compared with low-impact users, high-impact users were associated with higher mortality, bereavement episodes, and more out-of-hours general practitioner visits. The chronic high-impact users had distinct sequences of causes of emergency admissions most often consisting of chest infection, ischaemic heart disease, and cardio-pulmonary signs and/or symptoms. Conclusion: Chronic high-impact users constitute a small proportion of total patients, but they have increasingly high use of healthcare services. Short-term high-impact users represent largely end of life patients. They require prompt involvement of the palliative care team to reduce unnecessary readmissions to hospital.

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OBJECTIVE: Understanding the chronological order of the causes of readmissions may help us assess any repeated chain of events among high-impact users, those with high readmission rate. We aim to perform sequence analysis of administrative data to identify distinct sequences of emergency readmissions among the high-impact users. METHODS: A retrospective cohort of all cerebrovascular patients identified through national administrative data and followed for 4 years. RESULTS: Common discriminating subsequences in chronic high-impact users (n = 2863) of ischaemic stroke (n = 34208) were "urological conditions-chest infection," "chest infection-urological conditions," "injury-urological conditions," "chest infection-ambulatory condition," and "ambulatory condition-chest infection" (p < 0.01). Among TIA patients (n = 20549), common discriminating (p < 0.01) subsequences among chronic high-impact users were "injury-urological conditions," "urological conditions-chest infection," "urological conditions-injury," "ambulatory condition-urological conditions," and "ambulatory condition-chest infection." Among the chronic high-impact group of intracranial haemorrhage (n = 2605) common discriminating subsequences (p < 0.01) were "dementia-injury," "chest infection-dementia," "dementia-dementia-injury," "dementia-urine infection," and "injury-urine infection." Conclusion. Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community. CONCLUSION: Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community.

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OBJECTIVE: To apply group-based trajectory modelling (GBTM) to the hospital administrative data to evaluate, model and visualise trends and changes in the frequency of long-term hospital care use of the subgroups of patients with cerebrovascular conditions. DESIGN: A retrospective cohort study of patients with cerebrovascular conditions. SETTINGS: Secondary care of all patients with cerebrovascular conditions admitted to English National Hospital Service hospitals. PARTICIPANTS: All patients with cerebrovascular conditions identified through national administrative data (Hospital Episode Statistics) and subsequent emergency hospital admissions followed up for 4 years. MAIN OUTCOME MEASURE: Annual number of emergency hospital readmissions. RESULTS: GBTM model classified patients with intracranial haemorrhage (n=2605) into five subgroups, whereas ischaemic stroke (n=34 208) and transient ischaemic attack (TIA) (n=20 549) patients were shown to have two conventional groups, low and high impact. The covariates with significant association with high-impact users (17.1%) among ischaemic stroke were epilepsy (OR 2.29), previous stroke (OR 2.18), anxiety/depression (OR 1.63), procedural complication (OR 1.43), admission to intensive therapy unit (ITU) or high dependency unit (HDU) (OR 1.42), comorbidity score (OR 1.36), urinary tract infections (OR 1.32), vision loss (OR 1.32), chest infections (OR 1.25), living alone (OR 1.25), diabetes (OR 1.23), socioeconomic index (OR 1.20), older age (OR 1.03) and prolonged length of stay (OR 1.00). The covariates associated with high-impact users among TIA (20.0%) were thromboembolic event (OR 3.67), previous stroke (OR 2.51), epilepsy (OR 2.25), hypotension (OR 1.86), anxiety/depression (OR 1.63), amnesia (OR 1.62), diabetes (OR 1.58), anaemia (OR 1.55), comorbidity score (OR 1.39), atrial fibrillation (OR 1.27), living alone (OR 1.25), socioeconomic index (OR 1.13), older age (OR 1.04) and prolonged length of stay (OR 1.02). The high-impact users (0.5%) among intracranial haemorrhage were strongly associated with thromboembolic event (OR 20.3) and inversely related to older age (OR 0.58). CONCLUSION: GBTM effectively assessed trends in the use of hospital care by the subgroups of patients with cerebrovascular conditions. High-impact users persistently had higher annual readmission during the follow-up period.

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Background. Previous evidence on factors and causes of readmissions associated with high-impact users of stroke is scanty. The aim of the study was to investigate common causes and pattern of short- and long-term readmissions stroke patients by conducting a systematic review of studies using hospital administrative data. Common risk factors associated with the change of readmission rate were also examined. Methods. The literature search was conducted from 15 February to 15 March 2016 using various databases, such as Medline, Embase, and Web of Science. Results. There were a total of 24 studies (n = 2,126,617) included in the review. Only 4 studies assessed causes of readmissions in stroke patients with the follow-up duration from 30 days to 5 years. Common causes of readmissions in majority of the studies were recurrent stroke, infections, and cardiac conditions. Common patient-related risk factors associated with increased readmission rate were age and history of coronary heart disease, heart failure, renal disease, respiratory disease, peripheral arterial disease, and diabetes. Among stroke-related factors, length of stay of index stroke admission was associated with increased readmission rate, followed by bowel incontinence, feeding tube, and urinary catheter. Conclusion. Although risk factors and common causes of readmission were identified, none of the previous studies investigated causes and their sequence of readmissions among high-impact stroke users.

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INTRODUCTION: Aim of the study was to compare various outcomes of dementia patients with elderly patients without dementia by conducting a systematic review of previous population-based studies. METHODS: The relevant studies were retrieved from search of electronic databases. RESULTS: The pooled data from included 11 studies consisted of outcomes of 1,044,131 dementia patients compared to 9,639,027 elderly patients without dementia. Meta-analysis showed that the mortality in dementia patients was 15.3% as compared to 8.7% in non-dementia cases (RR 1.70, CI 95%, 1.27-2.28, p 0.0004). However, there was significant heterogeneity between the studies (p<0.00001). Dementia patients had significantly increased overall readmission rate (OR 1.18; 95% CI, 1.08-1.29, p<0.001). They had higher complication rates for urinary tract infections (RR 2.88; 95% CI, 2.45-3.40, p<0.0001), pressure ulcers (RR 184; 95% CI, 1.31-1.46, p<0.0001), pneumonia (RR 1.66; 95% CI, 1.36-2.02, p<0.0001), delirium (RR 3.10; 95% CI, 2.31-4.15, p<0.0001), and, dehydration and electrolyte imbalance (RR 1.87; 95% CI, 1.55-2.25, p<0.0001). Dementia patients had more acute cardiac events (HR 1.16; 95% CI, 1.06-1.28, p 0.002), while fewer revascularization procedures (HR 0.12; 95% CI, 0.08-0.20, p<0.001). Patients with dementia had lesser use of ITU (reduction by 7.5%; 95% CI, 6.9-8.1), ventilation (reduction by 5.4%; 95% CI, 5.0-5.9), and dialysis (reduction by 0.5%; 95% CI, 0.4-0.8). DISCUSSION: Compared to older adult population, patients with dementia had poorer outcome. Despite higher mortality rate and readmission rate, they underwent fewer interventions and procedures.

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