Analytical Approaches and Trends in the Determination of Psychoactive Drugs in Air

Understanding of the levels of psychoactive drugs in air is important for assessing both occupational and environmental exposure. Intelligence on the usage and manufacture of illegal drugs can also be gained. Environmental analysis and determination of air quality has recently expanded from its traditional focus to new pollutant categories that include illicit and psychoactive drugs. This is attributed to a greater part on the development of new, advanced techniques, such as liquid chromatography/mass spectrometry (LC/MS), allowing for the trace determination of such compounds down to the parts-per-trillion (ng/L) levels generally reported in air. Studies have also investigated the effects of firsthand and secondhand smoking of drugs, such as cocaine, cannabis and opium. Generally, these have shown secondhand smoke effects to be limited, apart from in the case of opium. Some studies have highlighted ill effects resulting through the exposure of vapors and dusts from the storage of drugs, but this has been shown to result from mould and other fungal contaminates. Investigations into the possible occupational exposures resulting from the use of anesthetic drugs in surgery and accident and emergency have focused on nitrous oxide, sevoflurane, methoxyflurane, isoflurane, propofol and fentanyl. This review focuses on developments and applications for the determination of psychoactive drugs in air.

An evaluation of the use of investigations in a nurse-led rapid access chest pain clinic

Background/Aims Chest pain is a common symptom, but its presentation and cause varies widely, making diagnosis a challenge. This study describes the authors' experience of a nurse-led rapid access chest pain clinic, and associated use of investigation and patient outcomes. Methods A retrospective service evaluation of patients referred to a nurse-led rapid access chest pain clinic was performed. Routinely-recorded data on patient demographics, symptoms, comorbidities, medications, cardiology clinic attendances and investigations were collected. In addition, admissions to accident and emergency or inpatient, death, acute myocardial infarction and percutaneous coronary intervention within 1 year were obtained. Results A total of 279 patients were included in the evaluation between January and February 2019. Chest pain was present as a symptom in 92.8% of patients, while 37.6% of patients had shortness of breath. Only 16.8% had typical angina, while 34.4% had atypical angina. The majority (93.9%) had two or fewer cardiology clinic appointments, the most common imaging investigation used was computed tomography coronary angiogram (47.3%) and 8.2% had a stress echocardiogram or invasive angiogram. Approximately one in five patients had a hospital admission within 1 year. The mortality rate within 1 year was 1.4%, but were all non-cardiac causes. Only 3.6% underwent percutaneous coronary intervention and there was only one mortality. Conclusions This service evaluation shows that a nurse-led rapid access chest pain clinic can be safe, efficient and closely adhere to National Institute for Health and Care Excellence guidelines. Many patients do not require unnecessary and potentially harmful investigations and revascularisation rates are low.

Identifying factors that promote and limit the effective use of real-time patient experience feedback: a mixed-methods study in secondary care

ObjectivesThe Friends and Family Test (FFT) is commissioned by the National Health Service (NHS) in England to capture patient experience as a real-time feedback initiative for patient-centred quality improvement (QI). The aim of this study was to create a process map in order to identify the factors that promote and limit the effective use of FFT as a real-time feedback initiative for patient-centred QI.SettingThis study was conducted at a large London NHS Trust. Services include accident and emergency, inpatient, outpatient and maternity, which routinely collect FFT patient experience data.ParticipantsHealthcare staff and key stakeholders involved in FFT.InterventionsSemi-structured interviews were conducted on 15 participants from a broad range of professional groups to evaluate their engagement with the FFT. Interview data were recorded, transcribed and analysed for using deductive thematic analysis.ResultsConcerns related to inefficiency in the flow of FFT data, lack of time to analyse FFT reports (with emphasis on high level reporting rather than QI), insufficient access to FFT reports and limited training provided to understand FFT reports for frontline staff. The sheer volume of data received was not amenable to manual thematic analysis resulting in inability to acquire insight from the free text. This resulted in staff ambivalence towards FFT as a near real-time feedback initiative.ConclusionsThe results state that there is too much FFT free text for meaningful analysis, and the output is limited to the provision of sufficient capacity and resource to analyse the data, without consideration of other options, such as text analytics and amending the data collection tool.

Cohort study to explore the association between the COVID-19 pandemic lockdown and admissions for violence in North East and North Cumbria

ObjectivesExplore the association between the first national lockdown associated with the COVID-19 pandemic on admissions for violence and the relationship with deprivation.DesignPopulation-based longitudinal cohort study.SettingNorth East and North Cumbria (NENC) area of England.ParticipantsAll individuals living in the NENC (total population 3.1 million) admitted 2017/2018, 2018/2019, 2019/2020.Main outcome measuresHospital Episode Statistics were extracted at Lower Layer Super Output Area and the Index of Multiple Deprivation 2019 decile applied. Directly standardised rates were explored for number of accident and emergency (A&E) attendances (per 1000); Alcohol-related admissions using Public Health England (PHE) Fingertips tool (per 100 000, ID 91414) and emergency admissions for violence (including sexual violence) (per 100 000) (ID 11201 classified by International Classification of Diseases (ICD)10 codes X85 to Y09).ResultsA&E attendances are higher in NENC compared with England (409.9 per 1000 v 359.2). A&E attendance was 81% higher in 2019/20 in the most deprived compared with the least deprived. Attendances dropped during the first national COVID-19 lockdown and by September 2020 had not returned to ‘normal’ levels.Admissions related to violence are a third higher in NENC (29% to 34% higher across 3 years) rates 7–10 times higher in most deprived than least deprived areas. Admission rates reduced during the first UK lock down but this bounced back by August higher than any of the previous 12 months.ConclusionEmergency admissions with violence appear to associate with the COVID-19 pandemic being initially higher than before the first national lockdown. This is in the context of overall A&E attendances which are lower post lockdown. Given that emergency admissions with violence have been consistently higher in the NENC compared with England over recent years, we suggest that targeted action is required in NENC to address health inequalities.

Impact of COVID-19 on the stroke rehabilitation pathway: multidisciplinary team reflections on a patient and carer journey from acute to community stroke services

A 62-year old man attended accident and emergency in June 2020 with dense right sided weakness, aphasia and confusion. Investigations revealed a left middle cerebral artery infarct, and he was admitted under the stroke team for ongoing inpatient rehabilitation. He was discharged home in September 2020 and received community stroke rehabilitation from physiotherapy, nursing, occupational therapy and speech and language therapy. He is now working towards a graded discharge from the Community Stroke and Neuro Rehab Team, after achieving his rehabilitation goals. In this case, the multidisciplinary team adopted different ways of working to accommodate the patients’ priorities while also negotiating the COVID-19 pandemic. This included taking a transdisciplinary approach to rehabilitation and considering alternative supported self-management strategies. This case highlighted several learning points, particularly the potential benefits of shared goal setting for patients with communication difficulties and transdisciplinary approaches to community stroke rehabilitation.

COMPARISON OF ALVARADO SCORE AND RIPASA SCORE IN THE ACCURATE DIAGNOSIS OF ACUTE APPENDICITIS IN COMBINED MILITARY HOSPITAL RAWALPINDI

Objective: To determine the diagnostic accuracy of Alvarado score and the RIPASA score for acute appendicitis using histopathology as a gold standard. Study Design: Cross sectional validation study. Place and Duration of Study: Department of General Surgery, Combined Military Hospital, Rawalpindi Pakistan, from Mar to Sep 2018. Methodology: A total number of 270 patients were included in the study presenting with pain right iliac fossa to the Accident and Emergency department. Surgeons and Seniors Residents in Surgery on call in the Accident and Emergency Department. Combined Military Hospital, Rawalpindi, scored the patients with suspicion of acute appendicitis with Alvarado Score and RIPASA score simultaneously. After appendectomy of these patients, the removed appendix was sent for histopathology to confirm whether it was normal or inflamed. A 2x2 table was used for calculating sensitivity, specificity and diagnostic accuracy of the RIPASA score and Alvarado Score. The two scoring systems were then compared for diagnostic accuracy. Results: In our study, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of RIPASA score and Alvarado score for diagnosing acute appendicitis were 92.1%, 62.1%, 95.2%, 48.6%, 88.9% and 72.6%, 68.9%, 95.1%, 23.2%, 72.2% respectively. Conclusion: The diagnostic accuracy of RIPASA score was more than that of Alvarado score in diagnosing acute appendicitis.

Study of Age and Gender Predilections amongst the Victims of Burns of Domestic Violence

Background: Human life from conception till death needs some sources of energy or heating mechanism to advance from a day to another in the process of livelihood. From innocent infants falling victims to fires, toddlers to scalds, youth to vitriolage and elders to enmity of a variety of sources or to their own debilitation bring them close to the fire source let them fell a prey to burns. Aim: To observe the age and gender predilections amongst the victims of burns Methods: The study was carried out among 250 victims of burns presented from December 2017 to August 2018 and reported in the Accident and Emergency Department of Mayo Hospital Lahore and filtered in Medicolegal Clinic of King Edward Medical University Lahore. Results: The study revealed maximum involvement of pediatric and geriatric age groups falling victim to burn incidents. In an analysis as a whole almost 84% victims were belonging to these two extremes of ages. Gender disparity showed a slight difference of just 10% showing female preponderance being exposed to burns. Keywords: Burns, Age, Gender, Variation, Disparity

Comparative effectiveness of ChAdOx1 versus BNT162b2 COVID-19 vaccines in Health and Social Care workers in England: a cohort study using OpenSAFELY

Background: The UK COVID-19 vaccination programme delivered both the BNT162b2 mRNA (Pfizer-BioNTech) and the ChAdOx1 (Oxford-AstraZeneca) vaccines during overlapping periods, providing a rare opportunity to emulate a trial that directly compares both vaccines using routinely-collected NHS data. Frontline Health and Social Care workers comprise a useful population to assess comparative effectiveness due to early vaccine eligibility and relatively high post-vaccination transmission risk due to occupational exposure. Methods: With the approval of NHS England we used the OpenSAFELY-TPP database, covering 40% of GP practices in England and linked to national coronavirus surveillance, hospital episodes, and death registry data, to compare the effectiveness of ChAdOx1 versus BNT162b2 in 1/3 million health and social care workers vaccinated between 4 January and 28 February 2021. Recipients were followed-up for 20 weeks. Second-dose effects were estimated under an intention-to-treat strategy. Primary outcomes were recorded SARS-CoV-2 infection, COVID-19-related accident and emergency attendance, and COVID-19-related hospital admission. Results: The cumulative incidence of each outcome was similar for both vaccines during the first 20 weeks post-vaccination. The cumulative incidence of recorded SARS-CoV-2 infection 6 weeks after vaccination with BNT162b2 was 19.2 per 1000 people (95%CI 18.6 to 19.7) and with ChAdOx1 was 18.9 (95%CI 17.6 to 20.3), representing a difference of -0.24 per 1000 people (95%CI -1.71 to 1.22). The difference in the cumulative incidence of COVID-19 accident and emergency attendance at 6 weeks was 0.01 per 1000 people (95%CI -0.27 to 0.28). For COVID-19 hospital admission, this difference was 0.03 per 1000 people (95%CI -0.22 to 0.27). Conclusion: In this cohort of healthcare workers where we would not anticipate vaccine type to be related to health status, we found no substantial differences in the incidence of SARS-CoV-2 infection or COVID-19 disease up to 20 weeks after vaccination. Incidence dropped sharply after 3-4 weeks and there were very few COVID-19 hospital attendance and admission events after this period. This is in line with expected onset of vaccine-induced immunity, and suggests strong protection against COVID-19 disease for both vaccines.

Determinants of Accident and Emergency Attendances and Emergency Admissions in Infants: Birth Cohort Study

Background: Understanding of drivers in increasing infant accident and emergency (A&E) attendances and emergency hospital admissions across England is limited. We examine variations in use of emergency hospital services among infants by local areas in England and investigate the extent to which infant and socio-economic factors explain these variations.Methods: Birth cohort study using linked administrative Hospital Episode Statistics data in England. Singleton live births between 1 April 2012 and 31 March 2019 were followed up for 1 year; from 1 April 2013 (from the discharge date of their birth admission) until their first birthday, death or 31 March 2019. Mixed effects negative binomial models were used to calculate incidence rate ratios for A&E attendances and emergency admissions and mixed effects logistic regression models estimated odds ratio of conversion (the proportion of infants subsequently admitted after attending A&E). Models were adjusted individual-level factors and included a random effect for local authority (LA).Results: The cohort comprised 3,665,414 births in 150 English LAs. Rates of A&E attendance and emergency admissions were highest amongst: infants born <32 weeks gestation; with presence of congenital anomaly; and to mothers <20-years-old. Area-level deprivation was positively associated with A&E attendance rates, but not associated with conversion probability. A&E attendance rates were highest in the North East (916 per 1000 child-years, 95%CI: 911 to 921) and London (876 per 1000, 95%CI: 874 to 879), yet London had the lowest emergency admission rates (232 per 1000, 95%CI: 231 to 234) and conversion probability (25% vs highest 39% in South West). Adjusting for individual-level factors did not significantly affect variability in A&E attendance and emergency admission rates by local authority.Conclusions: Drivers of A&E attendances and emergency admissions include individual-level factors such being born premature, with congenital anomaly and from socio-economically disadvantaged young parent families. Support for such vulnerable infants and families should be provided alongside preventative health care in primary and community care settings. Substantial geographical variations in rates were not explained by individual-level factors, suggest more detailed understanding of local and underlying service-level factors would provide targets for further research on mechanisms and policy priority.