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BackgroundMultimorbidity is recognised as a complex and growing health challenge. Currently there is no "gold standard" multimorbidity measure and few studies have compared measures in hospitalised patients.
ObjectivesWe aimed to evaluate two published multimorbidity measures in routine hospital episode data in NHS Grampian, Scotland.
MethodsWe used the Scottish Morbidity Record (SMR) data for the years 2009-2016. We included all adults admitted to hospital in the Grampian region of Scotland (population 588,100) during 2014. Morbidities were identified from inpatient admissions during the five years prior to admission date in 2014 (ICD-10 codes). Two multimorbidity measures were used: Charlson (Quan 2005), and Tonelli et al (2015); and multimorbidity was defined as ≥2 morbidities. Kappa statistics assessed agreement between the two measures in classifying patients as multimorbid. The association between multimorbidity and mortality, readmissions, and length of stay was examined using regression methods with odds ratios (OR) or incidence rate ratios (IRR) calculated as appropriate.
FindingsIn 41,545 adults (median age 62 years, 52.6% female), multimorbidity prevalence was 15.1% (95% CI 14.8%-15.5%) using Charlson and 27.4% (27.0%-27.8%) using Tonelli - agreement 85.1% (Kappa 0.57). After adjusting for covariates, multimorbidity was associated with an increased risk of longer length of stay, (Charlson IRR 1.10 (1.03, 1.18; p=0.005); Tonelli IRR 1.11 (1.04, 1.18; p<0.001)) and readmission (Charlson OR 2.06 (1.94, 2.19; p<0.001); Tonelli OR 2.12 (2.01, 2.22; p<0.001)). Multimorbidity had a higher risk of mortality when measured using Charlson (Charlson OR 2.71 (2.52, 2.92; p=<0.001); Tonelli OR (1.84 (1.72, 1.98; p<0.001)).
ConclusionsMultimorbidity measures operationalised in hospital episode data identified those at risk of poor outcomes and will be useful for future multimorbidity research and use in secondary care data systems.

Funding NHS Grampian Public Health Directorate funded the original study developing the dataset. This study was funded by NHS Grampian Endowment [Grant No. 18/10]. Acknowledgements We thank NHS Grampian who provided data and also the Grampian Data Safe Haven, who hosted the data and provided data management support and the linkage service. This work was supported by Health Data Research UK which receives its funding from HDR UK Ltd (HDR-5012) funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation (BHF) and the Wellcome Trust. We also acknowledge the non-financial support of our Study Steering Committee, which included clinical, epidemiological and health intelligence representation. ; Peer reviewed ; Publisher PDF

IntroductionMultimorbidity is a complex and growing health challenge. There is no accepted "gold standard" multimorbidity measure for hospital resource planning, and few studies have compared measures in hospitalised patients.
AimTo evaluate operationalisation of two multimorbidity measures in routine hospital episode data in NHS Grampian, Scotland.
MethodsLinked hospital episode data (Scottish Morbidity Record (SMR)) for the years 2009-2016 were used. Adults admitted to hospital as a general/acute inpatient during 2014 were included. Conditions (ICD-10) were identified from general/acute (SMR01) and psychiatric (SMR04) admissions during the five years prior to first admission in 2014. Two count-based multimorbidity measures were used (Charlson Comorbidity Index and Tonelli et al.), and multimorbidity was defined as ≥2 conditions. Kappa statistics assessed agreement. The association between multimorbidity and length of stay, readmission and mortality was assessed using logistic and negative binomial regression as appropriate.
ResultsIn 41,545 adults (median age 62 years, 52.6% female), multimorbidity prevalence was 15.1% (95% CI 14.8%, 15.5%) using Charlson and 27.4% (27.0%, 27.8%) using Tonelli – agreement 85.1% (Kappa 0.57). Multimorbidity prevalence, using both measures, increased with age. Multimorbidity was higher in males (16.5%) than females (13.9%) using the Charlson measure, but similar across genders when measured with Tonelli. After adjusting for covariates, multimorbidity remained associated with longer length of stay (Charlson IRR 1.1 (1.0, 1.2); Tonelli IRR 1.1 (1.0, 1.2)) and readmission (Charlson OR 2.1 (1.9, 2.2); Tonelli OR 2.1 (2.0, 2.2)). Multimorbidity had a stronger association with mortality when measured using Charlson (OR 2.7 (2.5, 2.9)), than using Tonelli (OR (1.8 (1.7, 2.0)).
ConclusionsMultimorbidity measures operationalised in hospital episode data identified those at risk of poor outcomes and such operationalised tools will be useful for future multimorbidity research and use in secondary care data systems. Multimorbidity measures are not interchangeable, and the choice of measure should depend on the purpose.
Hightlights

Operationalisation of two count-based multimorbidity measures using linked electronic hospitalepisode data was evaluated (Charlson and Tonelli).
First study to compare the Tonelli measure with another measure for investigating multimor-bidity in hospitalised patients.
Multimorbidity prevalence differed depending on measure used, but both multimorbidity mea-sures identified those at risk of poor outcomes.
Operationalised multimorbidity tools have uses for future multimorbidity research and use insecondary care data systems.
Multimorbidity measures are not interchangeable, and choice of measure should depend onpurpose.

IntroductionWhile chronic disease is a risk factor for dementia (Shang et al., 2020) studies addressing multimorbidity and dementia risk are limited. Multimorbidity leads to steeper dementia progression (Bauer, 2014; Haaksma, 2019) impacting cognitive dysfunction, cognitive decline and impairment (Wei, 2020; Vassilaki, 2015). Multimorbidity has generally been examined using a dose- response disease count, something cited as impractical for clinicians due to information deficits on identifying disease specific pathways (Whitty, 2020). Thus, differentiating disease clusters and dementia risk will provide insight into the pathophysiology of dementia, while informing priority targets for early intervention, potentially reducing burden and secondary care costs.
AimTo investigate dementia risk and mortality in older adults with different disease patterns, characteristics of hospital admissions, medication use and the role of locale of residence.
Data linkage and analysisWe used national data defined by the NHAIS, including basic demographics for all patients aged fifty-five plus and registered with a GP in Northern Ireland. The linked data comprised: Patient Admissions and Discharges (from 2013-2021); Electronically captured prescribing data, area-type of usual residence; Multiple Deprivation Indicators; and GRO mortality data (including cause of death). We identified multimorbidity through validated algorithms for ICD-10 coding of thirty morbidities in administrative hospital diagnostics data (Tonelli et al., 2019). The same data identified dementia-free patients at baseline. Latent Class Analysis assigned patient groups by the patterning of multimorbidity states, following them through the study period, with analysis in relation to subsequent diagnoses of both clinical dementia and mortality. As age has a potential modifier effect we tested through age group stratified analyses. A series of multinomial logistic regression models further examine (for the multimorbidity sub-groups of interest) risks associated socio-demographic, socio-economic, medication use and household indicators at the individual, family and area level.
ResultsMultimorbidity occurs in two thirds, approximately, of this hospital population of older adults. By age sixty-five years, most people are multimorbid. We identify subgroups of multimorbidity associated with dementia onset and mortality, combinations of diabetes, hypertension, chronic kidney disease and cancer multimorbidity are highlighted as higher-risk conditions for increased dementia incidence and mortality. Greater disease burden is associated with frequent healthcare service use, medication use and is more common in the most socioeconomically deprived, compared with the least deprived.
DiscussionEvidence on multimorbidity patterns and dementia is limited (Grande, 2021). Our study suggests that people with combinations of diabetes, hypertension, chronic kidney disease and cancer multimorbidity are associated with increased risks for dementia and socio demographic and economic circumstances further increase this risk. Overlapping combinations comprising chronic kidney disease + hypertension, or diabetes + hypertension, were a significant proportion of total secondary care costs for patients with multimorbidity; combinations comprising chronic heart failure + chronic kidney disease + hypertension had the highest proportion of total cost from potentially preventable emergency admissions (Stokes et al., 2021). Our finding support the body and mind connection in dementia development. Thus, we note that cardiovascular health is associated with dementia (Grande, 2021). Often described as a heart-brain connection, cardiovascular disease leads to higher dementia risk due to a number of mechanisms including but not limited to chronic inflammation (Grande, 2021). Identifying such high-risk groups will facilitate tailored interventions for dementia prevention and the reduction of healthcare use and costs.

Objectives: We aimed to describe clinical characteristics and outcomes of admitted COVID-19 patients in a Danish hospital setting where an early active government intervention was taken. Methods: This prospective cohort study included all patients admitted to the COVID-19 unit at Odense University Hospital from March 10 to April 21, 2020. Patients were assessed by a multidisciplinary team at admission. Outcome parameters were development of acute respiratory distress syndrome (ARDS), intensive care unit (ICU) admission, death and admission time. Results: We included 83 patients (median age 62 years, 62.7% male). At hospitalization, 31.3% needed oxygen supplementation and the median National Early Warning Score was four. Median admission time was 7 days (Interquartile ranges (IQR) 3−12). In total, ARDS was diagnosed in 33.7% (28/83) of the patients, corresponding to an incidence rate of 7.1 per 100 person days (95% CI: 4.1−10.2). Overall 13 patients (15.7%) were transferred to the ICU, of whom 11 (84.6%) received corticosteroids. No patients died while admitted to the ICU. Four patients (4.8%) died during admission. Conclusion: Despite similar patient characteristics compared to those reported by others, we found a low overall mortality of < 5%.

Acknowledgements: This work was funded by NHS Grampian. We thank NHS Grampian who provided data and also the Grampian Data Safe Haven, who hosted the data and provided data management support and the linkage service. We acknowledge the support from The Farr Institute of Health Informatics Research, Scotland. The Farr Institute is supported by a 10-funder consortium: Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the Medical Research Council, the National Institute of Health Research, the National Institute for Social Care and Health Research (Welsh Assembly Government), the Chief Scientist Office (Scottish Government Health Directorates), the Wellcome Trust, (MRC Grant Nos: Scotland MR/K007017/1). We also acknowledge the support of our Study Steering Committee, which included clinical, epidemiological and health intelligence representation. Funding: The study was funded by NHS Grampian, Public Health Directorate. ; Peer reviewed ; Publisher PDF

The Melbourne Health (MH) Social Work Residential Care Team (RCT) was established in 2002 as a new and innovative approach to aged care. The service employs three full‐time social workers and an Allied Health assistant with previous experience in aged care. The RCT works across the MH continuum of care with inpatients recommended for residential care. The service is predominantly patient‐ and family‐focused, but is also consultative to meet the education needs of MH staff and the community. This paper discusses the MH Social Work Residential Care model, reviews data collected since RCT implementation and the benefits shown for patients, their families and interdisciplinary staff. This paper discusses pressures and factors that impinge on the ability to discharge patients to residential care and explores recommendations for ongoing clinical practice as well as recommendations that the RCT has submitted to management for further consideration.

Objective: The new fluoroquinolones have demonstrated enhanced activity against the most common bacteria involved in lower respiratory tract infection (LRTI). Moxifloxacin is the most commonly prescribed respiratory flouroquinolone drug in Yemen. Pneumonia is a major and an on-going public health problem globally. With the widely use of fluoroquinolones in the clinical practice, the potential for developing resistance has become a concern. The aim of present study was to determine the trend of moxifloxacin resistant and the distribution of resistant for different sample types among hospitalised patients in Sana'a, Yemen. Methods: The study was performed at a private hospital in Sana'a, Yemen. The records were taken from the microbiology department for hospitalised patients. Moxifloxacin susceptibility samples were collected from January, 2017 to December, 2017. The moxifloxacin susceptibility was studied against several isolates. Full ethical clearance was obtained from the qualified authorities who approved the study design. All data were analyzed using SPSS Statistics version 21. Results: Out of 927 sample isolates, 580 (62.6%) were moxifloxacin resistant isolates and only 30.1% were sensitive. The Escherichia coli was observed in 24.4% of total sample isolates, followed by Pseudomonas aeruginosa (12.1%). From the study findings, 44.8% of total sample was isolated from sputum cultures. There was a statistically significant difference between bacteria type and culture results (P-value < 0.001). Moreover, 96.2% of Acinetobacter species and all Acinetobacter baumannii isolates were moxifloxacin resistant. The study findings reported that 70.4% of Escherichia coli isolates were resistant for moxifloaxin, followed by methicillin resistant staphylococcus aureus (64.7%), Klebsiella pneumonia (60.6%), and Pseudomonas aeruginosa (46.4%). Conclusion: This study reveals that varieties of pathogens are responsible for LRTI and moxifloxacin resistance has become a great public health issue. The possibility of reducing resistance by controlling the use of antibiotics is a reasonable approach. Inappropriate and irrational drug usage should be avoided. This study may help the government's regulatory authority to develop a policy about rational prescription of antibiotics to minimize resistance of new antibiotics and also to ensure the maximum safety to the health of patients. Peer Review History: Received25 September 2018; Revised 14 October; Accepted1 November, Available online 15 November 2018 Academic Editor:Dr. Jennifer Audu-Peter, University of Jos, Nigeria, drambia44@gmail.com UJPR follows the most transparent and toughest 'Advanced OPEN peer review' system. The identity of the authors and, reviewers will be known to each other. This transparent process will help to eradicate any possible malicious/purposeful interference by any person (publishing staff, reviewer, editor, author, etc) during peer review. As a result of this unique system, all reviewers will get their due recognition and respect, once their names are published in the papers. We expect that, by publishing peer review reports with published papers, will be helpful to many authors for drafting their article according to the specifications. Auhors will remove any error of their article and they will improve their article(s) according to the previous reports displayed with published article(s). The main purpose of it is 'to improve the quality of a candidate manuscript'. Our reviewers check the 'strength and weakness of a manuscript honestly'. There will increase in the perfection, and transparency. Received file: Reviewer's Comments: Average Peer review marks at initial stage: 6.0/10 Average Peer review marks at publication stage: 8.0/10 Reviewer(s) detail: Dr. Muhammad Zahid Iqbal, AIMST University, Malaysia, drmmziqbal@gmail.com Dr. A.A. Mgbahurike, University of Port Harcourt, Nigeria, amaka_mgbahurike@yahoo.com Similar Articles: PSEUDOMONAS AERUGINOSA SKIN-NASOPHARYNGEAL COLONIZATION IN THE IN-PATIENTS: PREVALENCE, RISK FACTORS AND ANTIBIOTIC RESISTANCE IN TERTIARY HOSPITALS IN SANA'A CITY -YEMEN

BACKGROUND: The COVID-19 pandemic represents an unprecedented challenge to healthcare systems and nations across the world. Particularly challenging are the lack of agreed-upon management guidelines and variations in practice. Our hospital is a large, secondary-care government hospital in Kuwait, which has increased its capacity by approximately 28% to manage the care of patients with COVID-19. The surge in capacity has necessitated the redeployment of staff who are not well-trained to manage such conditions. There was a great need to develop a tool to help redeployed staff in decision-making for patients with COVID-19, a tool which could also be used for training. METHODS: Based on the best available clinical knowledge and best practices, an eight member multidisciplinary group of clinical and quality experts undertook the development of a clinical algorithm-based toolkit to guide training and practice for the management of patients with COVID-19. The team followed Horabin and Lewis' seven-step approach in developing the algorithms and a five-step method in writing them. Moreover, we applied Rosenfeld et al's five points to each algorithm. RESULTS: A set of seven clinical algorithms and one illustrative layout diagram were developed. The algorithms were augmented with documentation forms, data-collection online forms and spreadsheets and an indicators' reference sheet to guide implementation and performance measurement. The final version underwent several revisions and amendments prior to approval. CONCLUSIONS: A large volume of published literature on the topic of COVID-19 pandemic was translated into a user-friendly, algorithm-based toolkit for the management of patients with COVID-19. This toolkit can be used for training and decision-making to improve the quality of care provided to patients with COVID-19.

Abstract Background Health literacy is simply defined as an individual's ability to access, understand and use information in ways that promote and maintain good health. Lower health literacy has been found to be associated with increased emergency department presentations and potentially avoidable hospitalisations. This study aimed to determine the health literacy of hospital inpatients, and to examine if associations exist between different dimensions of their health literacy, sociodemographic characteristics and hospital services use. Methods A written survey was sent to 3,252 people aged ≥18 years in English, Arabic, Chinese, Vietnamese, Italian or Greek. The survey included demographic and health questions, and the Health Literacy Questionnaire (HLQ). The HLQ is a multidimensional instrument comprising nine independent scales. Use of hospital services was measured by length of stay, number of admissions in 12 months and number of emergency department presentations. Effect size (ES) for standardised differences in means described the magnitude of differences in HLQ scale scores between demographic and socioeconomic groups. Results 385 questionnaires were returned (13%); mean age 64 years (SD 17), 49% female. Aged ≥65 years (55%), using the Internet < once a month (37%), failure to complete high school (67%), low household income (39%), receiving means-tested government benefits (61%) and being from a culturally and linguistically diverse (CALD) background (24%), were all associated with lower scores in some health literacy scales. Being aged ≥65 years, not currently employed, receiving government benefits, and being from a CALD background were also associated with increased use of some hospital services. There was no association between lower scores on any HLQ scale and greater use of hospital services. Conclusion We found no association between lower health literacy and greater use of hospital health services. However increased age, having a CALD background and not speaking English at home were all associated with having the most health literacy challenges Strategies to address these are needed to reduce health inequalities.