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The immediate management of poisoned patients is a major activity in emergency departments and acute medical wards. This can mean the neglect of more detailed enquiry that would make clear the underlying cause of the poisoning and suggest ways to reduce the risk of repeated poisoning for the individual and more generally. The history and circumstances of poisoning may make the precipitants evident, but it is still important to consider what factors contributed. Here, we divide poisoning into unintentional and intentional, and suggest how these major groups may be subdivided. There is a need in unintentional poisoning to consider whether the patient has been poisoned because of their vulnerability, for example, resulting from dementia. Where a carer such as a parent or partner has committed an error, they too may be vulnerable. If the poisoning is a result of error by a clinical professional, then the question of clinical competence can arise. If the poisoning is deliberate, mental ill-health may have contributed, and the patient may not have capacity to make decisions. There may also be a conflict between what the patient wants and what the clinician deems to be in the patient's best interest, in which case it may be necessary to consider mental capacity. A systematic approach to these important questions can offer the best prospect for prevention of further poisoning for the individual. Broader attempts to prevent poisoning require good data on the causes and circumstances in which it occurs, but these are often lacking.
To examine all-cause mortality differences among migrants from different countries/regions compared with native-born populations in England and Wales from 2007 to 2021 and assess whether migrant mortality patterns converge with or diverge from native-born trends over the study period. Descriptive, observational study analysing mortality trends over a 15-year period. England and Wales, using national mortality records and Census data. The study included all recorded deaths in England and Wales from 2007 to 2021, stratified by sex and country/region of birth. European age-standardised rates (EASRs) and standardised mortality ratios (SMRs) for all-cause mortality, with and without COVID-19-related deaths. Linear regressions were used to assess mortality trends over time. Mortality patterns varied significantly by country/region of birth. While most migrant groups had lower mortality rates than the native-born population at the beginning of the study period, this advantage declined for many in recent years. Migrants from Ireland, Scotland and Northern Ireland exhibited consistently worse mortality outcomes. Excluding COVID-19 deaths, 14 out of 19 migrant groups retained a mortality advantage, though trends indicate substantial heterogeneity. Some migrant groups, particularly from North and Central America and parts of Europe, showed improving mortality rates, whereas others, such as those from Bangladesh, converged towards native-born mortality levels. Despite lacking data on individual-level factors (e.g. duration of residence, socio-economic status and co-morbidities), this national-level study demonstrates important trends in migrant mortality. The findings highlight the urgent need for improved data to capture migration-related variables and enable a deeper understanding of the drivers behind observed trends. The decline in migrant mortality advantage over time for some groups highlights the importance of monitoring structural health inequalities and can inform targeted public health policies and more granular future research.
Between December 2022 and July 2024, the English National Health Service (NHS) experienced 27 periods of industrial action spanning 78 days, involving hospital and ambulance staff. We examined the direct and indirect impacts of these strikes on emergency department (ED) performanceDesign:A retrospective causal mediation analysis. Effects were estimated using mixed effects accelerated failure time, linear and generalised linear regression models with patient- and hospital-level covariates within a causal mediation framework. 20 major (Type 1) EDs in England with high-quality linkage across ED, inpatient, and imaging data. Patients attending these EDs between August 2022 and July 2024. A patient's time in ED analysed in relation to strike activity at the mid-point of attendance by one or more staff groups: (1) resident/junior doctors, (2) consultants, (3) both resident and consultant doctors, (4) paramedics and (5) nurses. Average duration of ED attendances reduced on days affected by residents' strikes (-12.6%, 95% CI -10.4% to -14.8%), consultant strikes (-5.6%, 95% CI -2.7% to -8.4%), paramedic strikes (-4.5%, 95% CI -2.0% to -6.8%), but increased when residents and consultants were on strike simultaneously (+7.2%, 95% CI 3.8%-10.7%). There were no significant changes to ED durations during nurse strikes (-1.7%, 95% CI -1.5% to 4.7%). Changes in emergency inpatient occupancy explained a proportion of the change in average ED durations (resident doctor 10.4%, consultants 53.3%, combined doctors 5.4% and paramedics 14.3%). The impact of strikes on ED attendance volumes was mixed. The net effect of these changes explained 1.5%, 16.8% and 28.8% of the change in average ED durations observed during residents, combined doctor and paramedic strikes, respectively. During the residents' strikes, patients were more likely to receive treatments in ED (adjusted incident risk ratio 1.013, 95% CI 1.008-1.018), but less likely to be admitted (adjusted odds ratio 0.963, 95% CI 0.946-0.980). Efforts to meet the 4-h target intensified during the resident, consultant and combined doctors strike, but reduced during the nurse and paramedic strikes. This explained 2.7% and 17.1% of the changes in average ED durations observed during the resident and consultant strikes, respectively. There were substantial reductions in many forms of planned hospital care during the resident, consultant and combined doctor strikes, but these did not contribute to the observed reductions in ED durations. Industrial action - particularly by resident and consultant doctors - was associated with shorter ED stays, partly mediated by greater emergency bed availability, lower demand and intensified throughput efforts. However, much of the reduction during resident strikes remained unexplained, suggesting unmeasured operational or behavioural adaptations. Substantial reductions in planned care did not significantly affect ED performance.
This study aimed to examine symptom patterns between healthcare workers (HCWs) with and without long COVID, identify the most common long COVID symptom groups and investigate how these symptom profiles vary across different ethnic groups, demographic characteristics, clinical factors and occupational roles in UK HCWS. We conducted a cross-sectional study using data from the United Kingdom Research study into Ethnicity and COVID-19 outcomes in Healthcare workers (UK-REACH) cohort study. Data were collected electronically between October 2021 and October 2022. United Kingdom. Individuals aged 16 years or older, residing in the UK, working as HCWs or ancillary workers in a healthcare setting and/or registered with one of seven major UK healthcare professional regulators. Long COVID was defined as symptoms persisting for ⩾12 weeks following SARS-CoV-2 infection. Our primary outcome was the presence or absence of particular groups of long COVID symptoms. We collapsed 28 symptoms into seven groups: cardiopulmonary, gastrointestinal, musculoskeletal, neurocognitive/neurologic, upper respiratory tract, psychological/social and systemic. Among 4033 HCWs with a history of COVID-19, those with long COVID (26.5%; 1067/4033) reported a higher prevalence of systemic, neurological and psychological symptoms compared with those without long COVID. Among those with long COVID, the most commonly reported symptom groups were neurocognitive/neurologic (63.4%), cardiopulmonary (40.0%) - highest among Asian HCWs at 45.6% - and systemic (54.6%), which particularly affected Black and Mixed ethnicities at 64.0% and 63.9%, respectively. In multivariable analyses, Asian HCWs had higher odds of experiencing cardiopulmonary symptoms (adjusted odds ratio (aOR): 1.62, 95% CI 1.04-2.51, p = 0.032), while female HCWs were more likely to experience gastrointestinal (aOR: 3.78, 95% CI 1.14-12.45, p = 0.029) and neurocognitive symptoms (aOR: 1.58, 95% CI 1.10-2.28, p = 0.014). Compared with those in medical roles, musculoskeletal symptoms were more commonly reported by those in nursing (aOR: 2.50, 95% CI 1.32-4.72, p = 0.005), allied health professional (aOR: 1.82, 95% CI 1.01-3.30, p = 0.048) and dental roles (aOR: 3.07, 95% CI 1.31-7.17, p = 0.010). Vaccination with two or three doses was protective against several symptom groups, including cardiopulmonary, musculoskeletal and neurocognitive symptoms. Our findings are the first to reveal distinct patterns in long COVID symptoms among HCWs with significant variations by ethnicity, sex and occupational role. These findings emphasise the need for targeted support strategies and workplace adjustments that consider both occupation-specific risks and individual sociodemographic factors.
Emerging evidence suggests that glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose co-transporter 2 (SGLT2) inhibitors may exert neuroprotective effects. However, the comparative efficacy of individual agents remains unclear. This network meta-analysis (NMA) aimed to evaluate the differential impacts of these therapies on the incidence of mental status changes, specifically delirium, depression, dementia and coma. A frequentist NMA was conducted using data from randomised controlled trials (RCTs) investigating GLP-1 receptor agonists or SGLT2 inhibitors. The robustness of the findings was verified through a Bayesian NMA framework. This study adopted a confirmatory framework focusing on pre-defined neuropsychiatric adverse outcomes in alignment with Cochrane recommendations. Included trials enrolled individuals without baseline cognitive or psychiatric disorders. The primary endpoint was the incidence of delirium, depression, dementia or coma during treatment. Secondary endpoints included changes in cognitive performance and drop-out rates. A total of 62 RCTs comprising 200,068 participants were included. Among all treatments, only high-dose dapagliflozin (10 mg/day) significantly reduced the occurrence of delirium and depression, particularly in patients with type 2 diabetes. Dulaglutide and liraglutide were the only agents associated with cognitive improvement. No significant benefits were observed for dementia or coma across all agents. This analysis highlights agent-specific neuroprotective profiles: SGLT2 inhibitors, especially high-dose dapagliflozin, may mitigate the onset of delirium and depression, while GLP-1 receptor agonists, notably dulaglutide and liraglutide, may enhance cognitive function. These findings warrant consideration in selecting antihyperglycemic therapies for individuals at elevated neuropsychiatric risk. PROSPERO CRD42024601021.The study protocol was approved by the Institutional Review Board of the Tri-Service General Hospital, National Defense Medical Center (TSGHIRB E202516007).
Retaining healthcare workers is often challenging. We studied predictors and patterns of leaving or wanting to leave healthcare work over time (attrition intentions and/or actions) in a UK cohort. Using five waves of longitudinal data (2020-2024), we performed group-based trajectory analysis to identify subgroups of healthcare workers with similar patterns of attrition intentions and/or actions over time. We described the characteristics of individuals in each trajectory, and used age-, sex- and occupation-adjusted multinomial logistic regression to identify predictors of trajectory membership. United Kingdom. Participants of the United Kingdom Research study into Ethnicity and COVID-19 outcomes in Healthcare workers (UK-REACH, N = 5499). 'Attrition intentions and/or actions' was defined as a healthcare worker having intentions (or having taken action) to leave their role (including early retirement). We identified three trajectories of attrition intentions and/or actions: consistently low (47.7%), moderate and increasing (36.8%) and consistently high (15.5%). Attrition intentions were linked to action: the majority of the 'consistently high' group had taken action to leave or change their job. Factors associated with the two latter trajectories included older age, job role (nursing, midwifery and dental), experiencing discrimination and poor mental health. Financial insecurity was strongly associated with attrition intentions and/or actions. Over half of UK healthcare workers surveyed intended or had taken action to leave or change their role. Interventions to enhance workforce sustainability could be targeted at older workers and those in nursing, midwifery and dental roles and focus on reducing discrimination, improving mental health and protecting the financial security healthcare worker jobs offer.
To examine time-trends in ethnic differences in UK medical specialty destinations at two key career points: entry into specialty training (CT/ST1) and awarding Certificate of Completion of Training (CCT). Repeated cross-sectional analysis using General Medical Council (GMC) secondary data; CT/ST1: 12 specialties, 2012-2022; CCT: 11 specialties, 2007-2021. Postgraduate specialty training groups within the UK National Health Service. Doctors with a UK Primary Medical Qualification (CT/ST1: 64,995; CCT: 62,380), categorised as White, Asian and other ethnic groups using GMC data. The ethnic distribution across specialties was examined using chi-squared tests. The temporal trend was evaluated with ordinary least squares regression of the effect size. Trends in over- and under-representation of ethnic groups within specialties were identified using Kendall's tau-b correlations. White doctors comprised the majority proportion (67.1% CT/ST1; 70.3% CCT), followed by Asian (23.4% CT/ST1; 22.6% CCT) and other ethnicities (9.5% CT/ST1; 7.1% CCT). Ethnic differences were statistically significant for all years except CCT in 2007, with larger effect sizes at CT/ST1. Effect sizes increased over time at both levels (CT/ST1 p = 0.041; CCT p = 0.024). Asian doctors were over-represented in Ophthalmology at both levels and Radiology at CT/ST1, and White doctors over-represented in Acute Care at CT/ST1 and Emergency Medicine at CCT. Persistent ethnic differences exist in UK medical specialty destinations. Systemic factors may therefore influence specialty choice, selection processes and progression to CCT. Future research should explore the underlying causes of ethnic differences between specialties to assess if biases affect career progression.
To identify and quantify key factors driving the decline in efficiency of NHS elective care, focusing on medical workforce dynamics, resource allocation and systemic inefficiencies. We hypothesised that medical workforce sickness absence and administrative turnover significantly affect productivity and backlog growth, instead medical workforce turnover has not effect. This research is a national retrospective observational study using monthly panel data from NHS Digital (January 2018-December 2023). Ordinary Least Squares regression and Generalised Method of Moments models were applied to estimate the impact of workforce and resource factors on productivity and backlog indicators. These methods will account for the unobserved factors and potential reverse causality problem. The study follows secondary care across all NHS Trusts in England, with performance measured at the Trust level. All NHS Trusts delivering elective surgical services between January 2018 and December 2023. The unit of analysis was Trust-month observations, encompassing all elective surgical patients treated in each Trust. (1) Average per capita completed surgery elective cases (proxy for productivity). (2) Ratio of incomplete elective surgery to average completed elective surgery cases (proxy for additional resources needed to meet demand). A one-percentage-point increase in NHS medical workforce sickness rates was associated with a 4.4% decrease in average completed elective cases (95% CI -0.0598 to -0.0272, p < 0.05). Gains in administrative staff reduced excess elective surgery incomplete cases by 14.4% (95% CI -0.155 to -0.133, p < 0.05). Findings were robust to controls for other workforce and resource-related variables. Workforce expansion alone will not resolve NHS elective surgery backlogs. Reducing medical sickness absence, enhancing staff wellbeing and ensuring adequate administrative capacity are critical to improving productivity and reducing waiting times.
This study aimed to evaluate the different risks of developing cardiovascular disease and major microvascular complications between sodium-glucose cotransporter-2 inhibitors (SGLT2i) and non-SGLT2i users in patients with type 2 diabetes (T2D) who do not have existing macrovascular or microvascular diseases. This study employed a retrospective, population-based cohort study design. Data were obtained from Taiwan's National Health Insurance Research Database, covering the period from January 1, 2008, to December 31, 2021. Propensity score matching was used to identify 91,327 matched pairs of SGLT2 inhibitor and dipeptidyl peptidase-4 (DPP-4) inhibitor users, 91,673 pairs of SGLT2 inhibitor and sulfonylurea users, and 20,857 pairs of SGLT2 inhibitor and glucagon-like peptide-1 receptor agonist (GLP-1 RA) users. The study included 1,145,035 patients diagnosed with T2D from the NHIRD. Cox proportional hazard models were used to assess the risk of outcomes. SGLT2i users showed a lower risk of coronary artery disease (0.80 (0.73-0.87), 0.78 (0.72-0.85) and 0.74 (0.64-0.86)), heart failure (0.44 (0.38-0.49), 0.56 (0.50-0.62) and 0.66 (0.55-0.78)), cardiovascular death (0.47 (0.40-0.56), 0.47 (0.40-0.55) and 0.68 (0.53-0.87)), dialysis (0.03 (0.02-0.05), 0.13 (0.10-0.17) and 0.16 (0.11-0.23)), vision-threatening retinopathy (0.58 (0.51-0.67), 0.59 (0.51-0.67) and 0.78 (0.62-0.98)), amputation (0.29 (0.20-0.41), 0.28 (0.21-0.38) and 0.61 (0.46-0.89)) and all-cause mortality (0.42 (0.39-0.445), 0.39 (0.37-0.42) and 0.68 (0.61-0.76]))when compared to DPP-4 inhibitors, sulfonylureas, and GLP-1 RA users, respectively. This study showed that SGLT2i use was associated with a lower risk of incident cardiovascular diseases, major microvascular complications and mortality compared with the use of DPP-4 inhibitors, sulfonylureas and GLP-1 RA in patients with T2D, who did not have macrovascular and microvascular diseases.
As the world population grows older, and as work retirement ages are being increasingly abolished in many countries, it is more likely that there will be elderly Heads of State who hold powerful positions which can result in great good or great harm. On the basis of this narrative review, we propose that elderly Heads of State over the age of 70 years have annual medical screening that includes comprehensive neuropsychological testing, psychiatric screening and brain imaging, so that we can be reassured of the mental integrity of such leaders and so as to prevent harmful decisions being taken by mentally-compromised Heads of State.
Significant differences in group-level performance have been identified in UK postgraduate medical examinations. However, few examinations have been investigated independently, and those that have, focus on a limited number of sociodemographic factors. This study addresses these gaps by identifying predictors of success in each UK postgraduate medical examination, accounting for prior academic attainment and other sociodemographic differences. Retrospective cohort study. Secondary care. Anonymised pass/fail data at the first attempt held within the General Medical Council Database were analysed for all candidates (UK medical school graduates [UKG] and international, non-UK graduates [IMG]) attempting a postgraduate examination between 2014 and 2020. Multivariate logistic regression models identified independent predictors of success at each postgraduate examination. During the study period, 180,890 examination first-attempts were made by candidates, and 121,745 (67.3%) passed at their first attempt. Multivariate regression models revealed that place of primary qualification, gender, age, ethnicity, religion, sexual orientation, disability and LTFT status were all statistically significant independent predictors of success or failure in written and clinical examinations. The strongest independent predictors of failing written and clinical examinations were being an IMG, being from a minority ethnic background and having a registered disability. This was the largest study to date investigating independent predictors of outcomes at each UK postgraduate medical examination. Significant differences in pass rates were seen according to sociodemographic differences in each examination. These data can be used by Medical Royal Colleges, the GMC and training institutions to guide more granular research and future interventions.
Genital schistosomiasis is a parasitic disease that affects both men and women as male and female genital schistosomiasis (MGS and FGS), respectively. Symptoms mimic sexually transmitted infections in men and women, owing to inflammation in the genital organs caused by migrating and trapped parasite ova. Schistosoma haematobium is the main causative organism, with an estimated 75% of infected women experiencing FGS, equating to approximately 56 million women mainly in sub-Saharan Africa. Estimates for MGS are mostly lacking, but numbers may be equivalent. S. haematobium has been found in hybridized forms with other Schistosoma animal species such as S. bovis, S. curassoni, S. mattheei and human schistosomes like S. mansoni. It is currently unclear what the impact of these species might be on genital schistosomiasis, including on clinical presentation, prognosis and management. In this review, we explore genital schistosomiasis and hypothesize the potential morbidity impact of hybrid species, along with highlighting future research needs. This article is part of the Royal Society Science+ meeting issue 'Parasite evolution and impact in action: exploring the importance and control of hybrid schistosomes in Africa and beyond'.
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