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BackgroundHospital administrative data, such as those provided by the Hospital Episode Statistics (HES) database in England, are increasingly being used for research and quality improvement. To date, no study has tried to quantify and examine trends in the use of HES for research purposes.ObjectiveTo examine trends in the use of HES data for research.MethodsPublications generated from the use of HES data were extracted from PubMed and analysed. Publications from 1996 to 2014 were then examined further in the Science Citation Index of the Thompson Scientific Institute for Science Information (Web of Science) for details of research specialty area.Results520 studies, categorised into 44 specialty areas, were extracted from PubMed. The review showed an increase in publications over the 19-year period with an average of 27 publications per year, however, with the majority of output observed in the latter part of the study period. The highest number of publications was in the Health Statistics specialty area.ConclusionThe use of HES data for research is becoming more common. Increase in publications over time shows that researchers are beginning to take advantage of the potential of HES data. Although HES is a valuable database, concerns exist over the accuracy and completeness of the data entered. Clinicians need to be more engaged with HES for the full potential of this database to be harnessed.

BackgroundElectronic health database (EHD) data are increasingly used by researchers. The major United Kingdom EHDs are the ‘Clinical Practice Research Datalink’ (CPRD), ‘The Health Improvement Network’ (THIN) and ‘QResearch’. Over time, outputs from these databases have increased but have not been evaluated.ObjectiveThis study compares research outputs from CPRD, THIN and QResearch assessing growth and publication outputs over a 10-year period (2004-2013). CPRD was also reviewed separately over 20 years as a case study.MethodsPublications from CPRD and QResearch were extracted using the Science Citation Index of the Thomson Scientific Institute for Scientific Information (Web of Science). THIN data were obtained from University College London and validated in the Web of Science. All databases were analysed for growth in publications, the speciality areas and the journals in which their data have been published.ResultsThese databases collectively produced 1,296 publications over a ten-year period, with CPRD representing 63.6% (n = 825 papers), THIN 30.4% (n = 394) and QResearch 5.9% (n = 77). Pharmacoepidemiology and General Medicine were the most common specialities featured. Over the 9-year period (2004–2013), publications for THIN and QResearch have slowly increased over time, whereas CPRD publications have increased substantially in the last 4 years with almost 75% of CPRD publications published in the past 9 years.ConclusionThese databases are enhancing scientific research and are growing yearly, however display variability in their growth. They could become more powerful research tools if the National Health Service and general practitioners can provide accurate and comprehensive data for inclusion in these databases.

Background End-stage renal disease (ESRD) patients receiving haemodialysis (HD) are a vulnerable group of patients with increased mortality from COVID-19. Despite improved understanding, the duration of host immunity following COVID-19 infection and role of serological testing alone or in addition to real-time reverse transcription polymerase chain reaction (rRT-PCR) testing in the HD population is not fully understood, which this study aimed to investigate. Methods There were two parts to this study. Between 15th March 2020 to 15th July 2020, patients receiving HD who tested positive on rRT-PCR for SARS-CoV-2 were recruited into the COVID-19 arm, whilst asymptomatic patients without a previous diagnosis of COVID-19 were recruited to the epidemiological arm of the Salford Kidney Study (SKS). All patients underwent monthly testing for anti-SARS-CoV-2 antibodies as per routine clinical practice since August 2020. The aims were twofold: firstly, to determine seroprevalence and COVID-19 exposure in the epidemiological arm; secondly, to assess duration of the antibody response in the COVID-19 arm. Baseline characteristics were reviewed between groups. Statistical analysis was performed using SPSS. Mann-Whitney U and Chi-squared tests were used for testing significance of difference between groups. Results In our total HD population of 411 patients, 32 were PCR-positive for COVID-19. Of the remaining patients, 237 were recruited into the SKS study, of whom 12 (5.1%) had detectable anti-SARS-CoV-2 antibodies. Of the 32 PCR-positive patients, 27 (84.4%) were symptomatic and 25 patients admitted to hospital due to their symptoms. Of the 22 patients in COVID-19 arm that underwent testing for anti-SARS-CoV-2 IgG antibodies beyond 7 months, all had detectable antibodies. A higher proportion of the patients with COVID-19 were frail compared to patients without a diagnosis of COVID-19 (64.3% vs 34.1%, p  = 0.003). Other characteristics were similar between the groups. Over a median follow up of 7 months, a higher number of deaths were recorded in patients with a diagnosis of COVID-19 compared to those without (18.7% vs 5.9%, p  = 0.003). Conclusions Serological testing in the HD population is a valuable tool to determine seroprevalence, monitor exposure, and guide improvements for infection prevention and control (IPC) measures to help prevent local outbreaks. This study revealed HD patients mount a humoral response detectable until at least 7 months after COVID-19 infection and provides hope of similar protection with the vaccines recently approved.

We present the case of a 25-year-old male who presented to A&E with isolated musical hallucinations, in the absence of audiological or neurological disease. The patient had a history of recreational drug use and a family history of psychosis. Hallucinations, which were preceded by discontinuation of alcohol and reinitiation of citalopram for depression, resolved spontaneously after three days. Aetiological factors are discussed alongside the existing literature. Whilst the underlying mechanisms underpinning musical hallucinations remain elusive, the case illustrates the potential role of alcohol withdrawal, serotonin toxicity, recreational drug use, and genetic vulnerability.

An 88-year-old female, afflicted by advanced frailty and multiple comorbidities, presented with respiratory symptoms to her general practitioner. Following a chest X-ray that revealed a fractured right atrial lead of her pacemaker, subsequent CT imaging confirmed the dislodgment of the fractured lead into the coronary sinus. Given her extensive comorbidities, a decision was made against intervention, opting to retain the fractured lead. This management plan was formulated after consultation with the cardiothoracic team, considering the patient's delicate health status and the potential risks associated with invasive intervention in her complex medical condition.IntroductionTrauma-induced lead fractures continue to be a notable concern in the realm of pacemaker implantation, despite their rarity. Encountering a fractured lead without a preceding history of trauma is even more infrequent. For patients undergoing pacemaker insertion for known diseases, complications, or preventative measures, this complication can lead to severe and potentially lethal consequences. Existing literature offers limited documentation of traumatic fractures and minimal evidence of spontaneous, atraumatic fractures. This case report sheds light on a specific instance involving a non-traumatic pacemaker lead fracture, contributing to the comprehension of this seldom-reported phenomenon.BackgroundThis case report is presented due to the infrequent occurrence of pacemaker lead fractures in medical practice. Furthermore, subsequent dislodgement following such fractures is even rarer. Typically, the treatment approach for a fractured lead involves removal and replacement of either the lead or the entire pacemaker; however, conservative strategies, as seen in the current case, are infrequently employed. The decision to pursue additional interventions necessitates a careful consideration of potential benefits against associated risks. In this presented case, the proposed management plan was deemed to carry an elevated risk, rendering surgical intervention or exploration inappropriate within the context of this complex clinical scenario. The report underscores the significance of adopting a nuanced approach to such cases, emphasizing that interventions should be informed by a comprehensive evaluation of the individual patient's health status and potential risks. It recognizes that surgical solutions may not universally apply in intricate situations.Case presentationThis case involves an 88-year-old female with a medical history notable for atrial fibrillation, ischemic heart disease, a permanent pacemaker, including a dual chamber device and an additional older right atrial lead observed on initial chest X-rays, type 2 diabetes mellitus, recurrent falls, haemochromatosis, and a documented Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) status from prior admissions.The initial pacemaker implantation predates 2007 and was performed at a different hospital, as Stepping Hill Hospital did not conduct Permanent Pacemaker Implantations (PPPMs) during that period. In 2012, a new right atrial lead was implanted at Stepping Hill Hospital, positioned more medially to the spine compared to the pre-existing right atrial lead.Chest X-ray from July 2020 showing the presence of two atrial leads, one of them was implanted before 2007, and the other was inserted in 2012 in Stepping Hill Hospital.Abstract 4-004 Figure 1In December 2020, the patient underwent a procedure involving the insertion of a new Right Ventricular lead due to an escalation in RV threshold. Concurrently, a transition was made to a single-chamber device tailored to manage atrial fibrillation (AF).Abstract 4-004 Figure 2In December 2022, the patient was admitted with chief complaints of chest pain, subsequently diagnosed with Non-ST Elevation Myocardial Infarction (NSTEMI), and managed through medical interventions. Her chest x-ray then was the one showed below:Abstract 4-004 Figure 3The fourth chest X-ray (CXR), conducted in July 2023, was initiated in response to respiratory symptoms as prompted by the patient's General Practitioner (GP). Subsequently, the GP sought cardiology advice and guidance via the electronic Referral Service (eRS) regarding the CXR findings. Notably, the report revealed the presence of a fractured tip of the right lead. It is important to highlight that the same abnormality was evident in a CXR conducted in March 2023, although it was not commented upon at that particular instance.Abstract 4-004 Figure 4Abstract 4-004 Figure 5The case involves a rare incident wherein the screw tip of one of the redundant right atrial leads underwent complete fracture, followed by an uncommon occurrence of dislodgment, a stage atypical for such events, as conventional expectations would entail the segment remaining affixed to the right atrium (RA). Determination of the precise embolized location of the lead tip is challenging through a standard chest X-ray (CXR).Identification of the redundant RA lead is facilitated by the distinct visualization of the tips of the two right ventricular (RV) leads, with the older lead exhibiting what appears to be a passive fix tip. The tip of one RA lead (medial, implanted at Stepping Hill Hospital in 2012) is discernible, while the tip of the more lateral RA lead (implanted considerably earlier at a different institution) remains elusive. Initial observations might suggest catching the tip ‘end on,’ but a closer examination refutes this assumption in the current context.In response to the aforementioned circumstances, the following measures were enacted:CT Scan for Positional Documentation:A CT scan was executed to meticulously document the precise position of the fractured lead.Consultation:Deliberation was given to engaging with cardiothoracic specialists or device/extraction experts, contingent on the CT findings.In the instance of this elderly lady, characterized by advanced age and significant co-morbidities, along with an existing DNACPR directive, any pursuit of intervention for lead removal was deemed excessively invasive, indisputably associated with a prohibitively high risk, and anticipated to yield minimal or no discernible benefits. Notably, the complication exhibited no correlation with preceding symptoms (Chest Pain in Dec 2022 or respiratory symptoms in July 2023). Despite the questionable utility of a CT scan without intervention, it was undertaken in her case to eliminate any association with respiratory symptoms. Moreover, the CT scan served as a judicious diagnostic tool to rule out other respiratory diseases as potential contributors to her current symptoms. The fractured lead, identified as a redundant RA lead, exerts no impact on the pacemaker's functionality. While an argument for anticoagulation in this context could be made, it is crucial to acknowledge that she is already undergoing anticoagulation therapy for atrial fibrillation (AF).The CT images below confirm the lead tip to be located in the coronary sinus. As previously indicated, the best course of action is to refrain from intervention. No causative factors for the respiratory symptoms were identified, and it is deemed appropriate to maintain the current management plan, leaving communication and coordination between the GP and the pacing clinic.Abstract 4-004 Figure 6Abstract 4-004 Figure 7Abstract 4-004 Figure 8It is noteworthy that this lady underwent a CT aorta in December 2022. Upon meticulous examination, the lead fracture can be discerned in those images as well.Abstract 4-004 Figure 9DiscussionWhat sets apart this case from prior reports is the prolonged duration during which the patient harbored a dislodged and embolized fractured lead tip before seeking medical attention. Notably, this case was managed in a comparatively conservative manner, evident in the March x-ray that disclosed the presence of the fracture; however, symptomatic presentation only occurred in July 2023. It is noteworthy that all previously documented patients underwent prompt treatment within days following lead fracture.Moreover, the extraction of the fractured lead tip posed a formidable challenge with the potential for various complications, such as coronary sinus rupture, cardiac perforation, tamponade, or fatal outcomes. The chest CT scan in this instance revealed that the dislodged end of the fractured lead had embolized and was securely situated in the coronary sinus. Given the precarious nature of attempting removal, which could entail severe complications, including the risk of coronary sinus rupture, a decision was made against undertaking any extraction procedures.

Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6–47·0) in 1990 to 63·4 years (63·1–63·7) in 2023. For males, mean age increased from 45·4 years (45·1–45·7) to 61·2 years (60·7–61·6), and for females it increased from 48·5 years (48·1–48·8) to 65·9 years (65·5–66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9–81·0) and for males 74·8 years (74·8–74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5–38·4) for females and 35·6 years (35·2–35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting—with enhanced estimation methods—the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.

Background Fabry disease is a rare genetic lysosomal storage disorder, whereby the accumulation of sphingolipids consequently leads to kidney structural damage and dysfunction. We explored the epidemiology of chronic kidney disease (CKD) among patients with Fabry disease at a major UK referral centre in Greater Manchester serving over 7 million people, to inform early predictors of kidney disease and possible treatment planning. Methods Data were sourced from the electronic records of registered participants from November 2020 to February 2022 of adults diagnosed with Fabry disease, with at least 1 year of follow-up. Four hundred and five participants (female = 223, male = 182) met the initial eligibility criteria. Our study focused on identifying factors linked to incident CKD, with 395 evaluable individuals undergoing outcome analysis over a median of 6.4 years. Results Findings concluded that 60.5% of participants received disease-modifying treatments, 29.7% experienced non-fatal cardiovascular events, 3.3% developed end-stage kidney disease (ESKD), and 7.3% died. Men had higher use of disease modifying therapy, progression to ESKD requiring kidney replacement therapy, cardiovascular events, and mortality compared to women. Subgroup analysis over 9 years revealed that older age, cardiovascular history, renin–angiotensin–aldosterone system inhibitor use, and higher urine albumin-to-creatinine ratio (uACR) were predictors of faster estimated glomerular filtration rate (eGFR) decline and increased mortality. At baseline, 47.8% of 249 patients with uACR data had CKD, and 25.4% of the remaining individuals developed CKD during follow-up, associated with higher uACR and lower, albeit normal eGFR levels. Conclusion Over 60% of Fabry disease patients are at lifetime risk of developing CKD, with a substantial risk of mortality, even with initially normal uACR and eGFR values. Graphical abstract

ObjectivesTo identify the key issues, problems, barriers and challenges particularly in relation to the quality of care in university hospitals in the Kingdom of Saudi Arabia (KSA), and to provide recommendations for improvement.MethodsA systematic search was carried out using five electronic databases, for articles published between January 2004 and January 2015. We included studies conducted in university hospitals in KSA that focused on the quality of healthcare. Three independent reviewers verified that the studies met the inclusion criteria, assessed the quality of the studies and extracted their relevant characteristics. All studies were assessed using the Institute of Medicine indicators of quality of care.ResultsOf the 1430 references identified in the initial search, eight studies were identified that met the inclusion criteria. The included studies clearly highlight a need to improve the quality of healthcare delivery, specifically in areas of patient safety, clinical effectiveness and patient-centredness, at university hospitals in KSA. Problems with quality of care could be due to failures of leadership, a requirement for better management and a need to establish a culture of safety alongside leadership reform in university hospitals. Lack of instructions given to patients and language communication were key factors impeding optimum delivery of patient-centred care. Decision-makers in KSA university hospitals should consider programmes and assessment tools to reveal problems and issues related to language as a barrier to quality of care.ConclusionsThis review exemplifies the need for further improvement in the quality of healthcare in university hospitals in KSA. Many of the problems identified in this review could be addressed by establishing an independent body in KSA, which could monitor healthcare services and push for improvements in efficiency and quality of care.

BackgroundDual antiplatelet therapy (DAPT) is the standard care following presentation with an acute coronary syndrome (ACS), but there remains debate regarding the relative benefits of the available P2Y12 receptor antagonists and their optimal combination with aspirin, particularly in those treated with percutaneous coronary intervention (PCI).MethodsWe performed a retrospective analysis of all PCI procedures undertaken in patients with ACS recorded in the British Cardiovascular Intervention Society (BCIS) database between 2007 and 2014 who were treated with DAPT consisting of aspirin and one of either clopidogrel, prasugrel or ticagrelor. The primary outcome measure was 30-day all-cause mortality, with secondary outcome measures of mortality at 1 and 5 years. Odds ratios (OR) for mortality were determined from multivariable logistic regression models allowing for clustering by hospital.ResultsAmong 259,255 eligible patients with 2 million person-years of observation, 7.4% (19,101) of patients had ticagrelor, 7.4% (n=19,161) had prasugrel and 85.2% (n=220,993) were treated with clopidogrel for ACS. A total of 41,107 (12.2%) patients died during a median of follow-up of 3.2 years (IQR: 1.6–5.2 years). Crude mortality rates were 34.7 (clopidogrel), 30.6 (prasugrel), and 36.9 deaths per 1000-person-years for ticagrelor treated ACS. In an age-sex unadjusted multinomial logistic regression analysis, mortality rates at 1 year in those treated with aspirin and ticagrelor were 64% lower [OR 0.34, 95% CI (0.32–0.36)] than those receiving DAPT with clopidogrel. DAPT with prasugrel was associated with a 27% lower mortality compared to DAPT with clopidogrel (OR 0.73 (0.69–0.77), p<0.0001). Stratifying by ACS status, the age-sex adjusted 1-year mortality rate for ticagrelor compared with clopidogrel was 63% lower [(OR 0.37 (0.34–0.40)] in STEMI and 80% lower in NSTEMI [(OR 0.20 (0.18–0.23), p<0.0001)]. The reduction in mortality at 1 year in the prasugrel versus clopidogrel group was relatively greater (57%) in individuals with STEMI [(OR 0.43 (0.40–0.45), p<0.0001)] compared to those with NSTEMI [(OR 0.64 (0.55–0.74), p<0.0001)].ConclusionsThis very large, real-world dataset of patients presenting with ACS demonstrates a significant net clinical benefit favouring the use of ticagrelor and prasugrel over clopidogrel in ACS patients for DAPT. This analysis concurs with the data from the landmark TRITON and PLATO RCTs, suggesting these agents should be considered as the standard of care in the management of ACS.Conflict of InterestNone

Introduction Bariatric surgery (BS) has emerged an effective intervention in achieving significant and sustained weight loss in patients with type 2 diabetes (T2D). However, comprehensive data on the long-term impact of BS on hypertension is scarce. We aimed to investigate the long-term impact of BS on blood pressure management in individuals within a T2D cohort. Methods This retrospective cohort study was conducted on 119 patients who underwent BS between 2009 and 2012. Baseline and follow-up observations, including blood pressure, HbA1c, BMI, and antihypertensive medication use were obtained from electronic patient records at regular intervals up to and beyond 10-year follow-up. Results The median follow-up period for the 119 patients was 11.5 years. Mean fall in BMI 4–8 weeks post-surgery was 12%. A sustained reduction in systolic BP was observed up to 10 years post-surgery (154.5 mmHg pre-op vs. 132.8 mmHg at 10 years; p  < 0.0001. From 5 years onwards, there were increases in mean glycated hemoglobin (HbA1c) and body mass index (BMI). At latest follow-up (> 5 years after bariatric surgery), the number of individuals prescribed an antihypertensive agent started to increase. This is in the context of the number of the number of individuals on 2–3 antihypertensive agents declining up until 5 years post-BS. Specifically, there was a reduction in the number of prescriptions of an antihypertensive agent over time from 164 prescriptions pre-operatively to 81 at 8 weeks post-operatively, 78 at 6 months, 72 at 1 year, 66 at 5 years before rising at 10 years to 95 prescriptions. Conclusions Our study shows an overall benefit in the years after bariatric surgery in terms of blood pressure and requirement for antihypertensive medication. However, at 5 years and beyond after surgery, the beneficial effect of bariatric surgery diminishes with respect to an increase in number of antihypertensive medication prescriptions, BMI, and HbA1c.