Prisoners are known to report worse health than the general population. Research has also shown that the prison population counts disproportionally more people with a lower socioeconomic status ...(SES), making it difficult to determine whether the worse self‐reported health of prisoners is an effect of their detention or of their lower SES. This study assesses the influence of being in prison on self‐rated health and if (and how) this relationship is mediated by SES. Data from detainees were collected in 12 Flemish prisons. To compare with the general population, data from the Belgian national health survey 2013 were used. To estimate the direct and indirect effect of being in prison on self‐reported health, mediation analysis was carried out by means of natural effect models using nested counterfactuals. Following previous literature we find that prisoners report worse health than the general population and that SES has a significant influence on subjective health. Our results showed that the direct effect (exp(B) = 3.43; 95% CI: 2.924–4.024) of being in prison on self‐reported health is larger than the indirect effect (through SES) (exp(B) = 1,236; 95% CI: 1.195–1.278), thus contradicting the hypotheses in previous literature that the SES is the main explanation for variation in self‐reported health among prisoners. Lastly, the effect of SES on health is more important for the general population compared to detainees, suggesting that for prisoners the effect of being in prison seems to surpass the effect of SES on health.
Seizures and status epilepticus (SE) are frequent complications of acute subdural hematoma (aSDH) associated with increased morbidity and mortality. Therefore, we aimed to evaluate whether invasive ...subdural electroencephalogram recording leads to earlier seizure detection and treatment initiation in patients with aSDH.
Prospective, single-center, cohort trial.
Neurologic and neurosurgical ICUs of one academic hospital in Germany.
Patients with aSDH undergoing surgical treatment. In total, 76 patients were enrolled in this study, 31 patients (40.8%) were assigned to the invasive electroencephalogram (iEEG) monitoring group and 45 patients (59.2%) to control group.
The electrode group was implanted with a subdural strip electrode providing up to 7 days of real-time electroencephalogram recording in the neurointensive care unit, whereas the control group received regular normal surface electroencephalograms during the 7-day period. The primary outcomes were the prevalence and time to seizures and SE occurrence. Secondary outcomes included neurologic outcomes assessed using the Glasgow Outcome Scale (GOS) at discharge and 6-month follow-up and the prevalence of focal structural epilepsy within 2 years after discharge.
The trial was stopped after a study committee meeting when the prespecified criteria were met. The iEEG and control groups were well-matched for clinical characteristics at admission. Frequencies of seizures and SE detection were significantly higher in the iEEG group than in the control group (61% vs 15.6%; p < 0.001 and 38.7% vs 11.1%; p = 0.005). Time to seizure and SE detection was significantly earlier (median 29.2 vs 83.8 hr; p = 0.018 and 17.2 vs 83.8 hr; p = 0.033) in the iEEG group than in the control group. Favorable outcomes (GOS 4-5) were more frequently achieved in the iEEG group than in the control group (58% vs 31%; p = 0.065). No significant differences were detected in long-term mortality or post-traumatic epilepsy.
Invasive subdural electroencephalogram monitoring is valuable and safe for early seizure/SE detection and treatment and might improve outcomes in the neurocritical care of patients with aSDH.
Objectives
A high incidence of delirium has been reported in older patients with Coronavirus disease 2019 (COVID‐19). We aimed to identify determinants of delirium, including the Clinical Frailty ...Scale, in hospitalized older patients with COVID‐19. Furthermore, we aimed to study the association of delirium independent of frailty with in‐hospital outcomes in older COVID‐19 patients.
Methods
This study was performed within the framework of the multi‐center COVID‐OLD cohort study and included patients aged ≥60 years who were admitted to the general ward because of COVID‐19 in the Netherlands between February and May 2020. Data were collected on demographics, co‐morbidity, disease severity, and geriatric parameters. Prevalence of delirium during hospital admission was recorded based on delirium screening using the Delirium Observation Screening Scale (DOSS) which was scored three times daily. A DOSS score ≥3 was followed by a delirium assessment by the ward physician In‐hospital outcomes included length of stay, discharge destination, and mortality.
Results
A total of 412 patients were included (median age 76, 58% male). Delirium was present in 82 patients. In multivariable analysis, previous episode of delirium (Odds ratio OR 8.9 95% CI 2.3–33.6 p = 0.001), and pre‐existent memory problems (OR 7.6 95% CI 3.1–22.5 p < 0.001) were associated with increased delirium risk. Clinical Frailty Scale was associated with increased delirium risk (OR 1.63 95%CI 1.40–1.90 p < 0.001) in univariable analysis, but not in multivariable analysis. Patients who developed delirium had a shorter symptom duration and lower levels of C‐reactive protein upon presentation, whereas vital parameters did not differ. Patients who developed a delirium had a longer hospital stay and were more often discharged to a nursing home. Delirium was associated with mortality (OR 2.84 95% CI1.71–4.72 p < 0.001), but not in multivariable analyses.
Conclusions
A previous delirium and pre‐existent memory problems were associated with delirium risk in COVID‐19. Delirium was not an independent predictor of mortality after adjustment for frailty.
Key points
A previous episode of delirium and pre‐existent memory problems were independent predictors of delirium risk in older adults hospitalized with COVID‐19.
Reports on the association of delirium with poor outcomes, independent of frailty, in older hospitalized COVID‐19 patients have been conflicting.
In this study, delirium was not a predictor of in‐hospital mortality independent of frailty.
Objectives
Recent research has shown that ethnic minorities still have less access to medical care and are less satisfied with the treatment they receive and the outcomes of the health care process. ...This article assesses how migrants in Europe experience access, treatment and outcomes in the European health care systems.
Methods
Data were obtained from the QUALICOPC study (Quality and Costs of Primary Care in Europe). Regression analyses were used to estimate the access, treatment and outcomes of care for ethnic minorities.
Results
In several countries, migrants experience that the opening hours of their GP practice were too limited and indicate that the practice was too far away from their work or home (lower access). They are more likely to report negative patient–doctor communication and less continuity of care than native patients (worse treatment). In addition, they are less satisfied with the care they received and are more likely to postpone care (worse outcomes).
Conclusions
In general, migrants are still disadvantaged during the health care process. However, our results also indicate that satisfaction with the health care process improves for second-generation migrants in comparison with first-generation migrants.
Recent figures show that discrimination in healthcare is still persistent in the European Union. Research has confirmed these results but focused mainly on the outcomes of perceived discrimination. ...Studies that take into account socioeconomic determinants of discrimination limit themselves to either ethnicity, income or education. This article explores the influence of several socioeconomic indicators (e.g. gender, age, income, education and ethnicity) on perceived discrimination in 30 European countries. Data from the QUALICOPC study were used. These data were collected between October 2011 and December 2013 in the participating countries. In total, 7183 GPs (general practitioners) and 61932 patients participated in the study, which had an average response rate of 74.1%. Data collection was co‐ordinated by NIVEL (Dutch Institute for Research of Health Care). Bivariate binomial logistic regressions were used to estimate the impact of each socioeconomic indicator on perceived discrimination. Multivariate logistic regressions were used to estimate the unique effect of each indicator. Results indicate that in Europe, overall 7% of the respondents felt discriminated, ranging between 1.4% and 12.8% at the country level. With regard to socioeconomic determinants in perceived discrimination, income and age are both important indicators, with lower income groups and younger people having a higher chance to feel discriminated. In addition, we find significant influences of education, gender, age and ethnicity in several countries. In most countries, higher educated people, older people, women and the indigenous population appeared to feel less discriminated. In conclusion, perceived discrimination in healthcare is reported in almost all European countries, but there is large variation between European countries. A high prevalence of perceived discrimination within a country also does not imply a correlation between socioeconomic indicators and perceived discrimination.
Pulmonary valve replacement is very common among patients with congenital heart disease. The Carpentier Edwards Perimount valve (Edwards Lifesciences, Irvine, Calif), which was originally designed ...for the aortic position is among the most implanted valves. We aim to describe the follow-up of this valve in the pulmonary position.
Patients with a Perimount valve implanted between 2003 and 2013 in the University Medical Center Groningen were followed for the primary end point reintervention, defined as surgical or transcatheter valve replacement. Secondary end point was the occurrence of valve failure, defined as significant valvular regurgitation or stenosis. Explanted valves were histologically examined.
Forty-five patients (median age at operation 27.8 years, 55.6% women) had a mean follow-up duration of 5.8 ± 3.3 years. There were 7 reinterventions (5 surgical and 2 transcatheter). Freedom from reintervention was respectively 95% ± 4% and 83% ± 8% at 5- and 10- years of follow-up. Freedom from valve failure was 75% ± 4% at 2 years, 65% ± 8% at 5 years of follow-up and 57% ± 10% at 10 years of follow-up. Morphology evaluation (n = 4) showed stiffened valves in the open position, with extensive fibrous tissue overgrowth on the leaflets and a variable proliferation of myofibroblasts.
The Perimount valve has adequate function in the pulmonary valve position at 5 years of follow-up, although after 10 years of follow-up valve failure and reinterventions are common. Explanted valves show retraction and stiffening of the leaflets due to a fibrotic layer on both sides of the leaflet.
Aims/hypothesis
Mitochondrial dysfunction, which can be approximated by blood mitochondrial DNA copy number (mtDNA-CN), has been implicated in the pathogenesis of type 2 diabetes mellitus. Thus far, ...however, insights from prospective cohort studies and Mendelian randomisation (MR) analyses on this relationship are limited. We assessed the association between blood mtDNA-CN and incident type 2 diabetes using multivariable-adjusted regression analyses, and the associations between blood mtDNA-CN and type 2 diabetes and BMI using bi-directional MR.
Methods
Multivariable-adjusted Cox proportional hazard models were used to estimate the association between blood mtDNA-CN and incident type 2 diabetes in 285,967 unrelated European individuals from UK Biobank free of type 2 diabetes at baseline. Additionally, a cross-sectional analysis was performed to investigate the association between blood mtDNA-CN and BMI. We also assessed the potentially causal relationship between blood mtDNA-CN and type 2 diabetes (
N
=898,130 from DIAGRAM,
N
=215,654 from FinnGen) and BMI (
N
=681,275 from GIANT) using bi-directional two-sample MR.
Results
During a median follow-up of 11.87 years, 15,111 participants developed type 2 diabetes. Participants with a higher level of blood mtDNA-CN are at lower risk of developing type 2 diabetes (HR 0.90 95% CI 0.89, 0.92). After additional adjustment for BMI and other confounders, these results attenuated moderately and remained present. The multivariable-adjusted cross-sectional analyses showed that higher blood mtDNA-CN was associated with lower BMI (−0.12 95% CI −0.14, −0.10) kg/m
2
. In the bi-directional MR analyses, we found no evidence for causal associations between blood mtDNA-CN and type 2 diabetes, and blood mtDNA-CN and BMI in either direction.
Conclusions/interpretation
The results from the present study indicate that the observed association between low blood mtDNA-CN and higher risk of type 2 diabetes is likely not causal.
Graphical abstract
The COVID-19 pandemic has highlighted embedded inequities and fragmentation in our health systems. Traditionally, structural issues with health professional education perpetuate these. COVID-19 has ...highlighted inequities, but may also be a disruptor, allowing positive responses and system redesign. Examples from health professional schools in high and low- and middle-income countries illustrate pro-equity interventions of current relevance. We recommend that health professional schools and planners consider educational redesign to produce a health workforce well equipped to respond to pandemics and meet future need.
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