Acceptability of a decision-support electronic health record system and its impact on diabetes care goals in South Asia: a mixed-methods evaluation of the CARRS trial

AIMS

To describe physicians' acceptance of decision-support electronic health record system and its impact on diabetes care goals among people with Type 2 diabetes.

METHODS

We analysed data from participants in the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, who received the study intervention (care coordinators and use of a decision-support electronic health record system; n=575) using generalized estimating equations to estimate the association between acceptance/rejection of decision-support system prompts and outcomes (mean changes in HbA_1c , blood pressure and LDL cholesterol) considering repeated measures across all time points available. We conducted in-depth interviews with physicians to understand the benefits, challenges and value of the decision-support electronic health record system and analysed physicians' interviews using Rogers' diffusion of innovation theory.

RESULTS

At end-of-trial, participants with diabetes for whom glycaemic, systolic blood pressure, diastolic blood pressure and LDL cholesterol decision-support electronic health record prompts were accepted vs rejected, experienced no reduction in HbA_1c [mean difference: -0.05 mmol/mol (95% CI -0.22, 0.13); P=0.599], but statistically significant improvements were observed for systolic blood pressure [mean difference: -11.6 mmHg (95% CI -13.9, -9.3); P ≤ 0.001], diastolic blood pressure [mean difference: -5.2 mmHg (95% CI -6.5, -3.8); P ≤ 0.001] and LDL cholesterol [mean difference: -0.7 mmol/l (95% CI -0.6, -0.8); P ≤0.001], respectively. The relative advantages and compatibility of the decision-support electronic health record system with existing clinic set-ups influenced physicians' acceptance of it. Software complexities and data entry challenges could be overcome by task-sharing.

CONCLUSION

Wider adherence to decision-support electronic health record prompts could potentially improve diabetes goal achievement, particularly when accompanied by assistance from a non-physician health worker.

Feasibility and Results of Cancer Registry and Noncommunicable Disease Cohort Data Linkages in India

Background: Cancer registries worldwide are vital to determine cancer burden, plan cancer control measures, and facilitate research. Population-based cancer registries are a priority for LMICs by the UICC; the National Cancer Registry Program (NCRP) of India oversees 28 such registries. A primary function of registries is to combine data for the same individual from multiple sources. For other disease cohorts where cancer is an outcome of interest, registries can potentially connect information by linking datasets together. Barriers to successful registration and linkages include systems in which cancer is not a notifiable disease, no universal unique individual identifier exists, and lack of trained personnel. This study utilizes technology and infrastructure to develop better linkages, surveillance, and outcomes. Aim: To assess the feasibility of linking large cohorts designed for cardio-metabolic disease research with cancer registries in New Delhi and Chennai; determine additional steps required for linkage accuracy and completeness; and develop detailed protocols for future applications. Methods: A pilot protocol for linkage between a large diabetes cohort and cancer registries in Delhi and Chennai was developed using MatchPro, a probabilistic record linkage program developed for cancer registries. Probabilistic software links datasets together in the presence of uncertainty (eg misspelled or abbreviated names) to identify record pairs with high probability of representing the same individual. For this study, algorithms were developed to address unique aspects of names and demographics in India. The software and algorithms focused on: detecting duplicates in cancer registries; and linking registries with external files from diabetes cohorts. In Delhi, 3 1-year datasets covering 3 years (2010, 2011, 2012) were linked with the diabetes cohort; in Chennai, the linkage included 3 5-year datasets covering 15 years (2000-04, '05-'09, '10-'14). The unique ID (Aadhaar) is not collected or linked systematically between different systems at this point in time. Results: Linkage attempts yielded potential matches ranked according to probabilistic scores; highest scores were reviewed to determine true matches. In Chennai, this process yielded: (2010-2014) 21% self-reported (SR) cases matching perfectly, 36% requiring follow-up, 13 nonreported (NR) cases found; 2005-2009: 33% SR cases matched perfectly, 1 NR case found; 2000-2004: 1 NR case. Also, 2 training workshops on data linkages and software were held. Conclusion: Linkages between cancer registries and other data sources are feasible in LMICs using probabilistic record linkage software augmented by manual matching. Future efforts to use existing epidemiologic resources (cohorts) and cancer research infrastructure (registries and clinical centers) can enhance research including understanding shared risk factors and pathophysiologic mechanisms e.g., between cancer and other NCD.

Pauling Entropy, Metastability, and Equilibrium in Dy_{2}Ti_{2}O_{7} Spin Ice

Determining the fate of the Pauling entropy in the classical spin ice material Dy_{2}Ti_{2}O_{7} with respect to the third law of thermodynamics has become an important test case for understanding the existence and stability of ice-rule states in general. The standard model of spin ice-the dipolar spin ice model-predicts an ordering transition at T≈0.15  K, but recent experiments by Pomaranski et al. suggest an entropy recovery over long timescales at temperatures as high as 0.5 K, much too high to be compatible with the theory. Using neutron scattering and specific heat measurements at low temperatures and with long timescales (0.35  K/10^{6}  s and 0.5  K/10^{5}  s, respectively) on several isotopically enriched samples, we find no evidence of a reduction of ice-rule correlations or spin entropy. High-resolution simulations of the neutron structure factor show that the spin correlations remain well described by the dipolar spin ice model at all temperatures. Furthermore, by careful consideration of hyperfine contributions, we conclude that the original entropy measurements of Ramirez et al. are, after all, essentially correct: The short-time relaxation method used in that study gives a reasonably accurate estimate of the equilibrium spin ice entropy due to a cancellation of contributions.

Association between empirically derived dietary patterns with blood lipids, fasting blood glucose and blood pressure in adults - the India migration study

BACKGROUND

Dietary patterns (DPs) in India are heterogenous. To date, data on association of indigenous DPs in India with risk factors of nutrition-related noncommunicable diseases (cardiovascular disease and diabetes), leading causes of premature death and disability, are limited. We aimed to evaluate the associations of empirically-derived DPs with blood lipids, fasting glucose and blood pressure levels in an adult Indian population recruited across four geographical regions of India.

METHODS

We used cross-sectional data from the Indian Migration Study (2005-2007). Study participants included urban migrants, their rural siblings and urban residents and their urban siblings from Lucknow, Nagpur, Hyderabad and Bangalore (n = 7067, mean age 40.8 yrs). Information on diet (validated interviewer-administered, 184-item semi-quantitative food frequency questionnaire), tobacco consumption, alcohol intake, physical activity, medical history, as well as anthropometric measurements were collected. Fasting-blood samples were collected for estimation of blood lipids and glucose. Principal component analysis (PCA) was used to identify major DPs based on eigenvalue> 1 and component interpretability. Robust standard error multivariable linear regression models were used to investigate the association of DPs (tertiles) with total cholesterol (TC), low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), triglycerides, fasting-blood glucose (FBG), systolic and diastolic blood pressure (SBP and DBP) levels.

RESULTS

Three major DPs were identified: 'cereal-savoury' (cooked grains, rice/rice-based dishes, snacks, condiments, soups, nuts), 'fruit-vegetable-sweets-snacks' (Western cereals, vegetables, fruit, fruit juices, cooked milk products, snacks, sugars, sweets) and 'animal food' (red meat, poultry, fish/seafood, eggs) patterns. High intake of the 'animal food' pattern was positively associated with levels of TC (β = 0.10 mmol/L; 95% CI: 0.02, 0.17 mmol/L; p-trend = 0.013); LDL-C (β = 0.07 mmol/L; 95% CI: 0.004, 0.14 mmol/L; p-trend = 0.041); HDL-C (β = 0.02 mmol/L; 95% CI: 0.004, 0.04 mmol/L; p-trend = 0.016), FBG: (β = 0.09 mmol/L; 95% CI: 0.01, 0.16 mmol/L; p-trend = 0.021) SBP (β = 1.2 mm/Hg; 95% CI: 0.1, 2.3 mm/Hg; p-trend = 0.032); DBP: (β = 0.9 mm/Hg; 95% CI: 0.2, 1.5 mm/Hg; p-trend = 0.013). The 'cereal-savoury' and 'fruit-vegetable-sweets-snacks' patterns showed no association with any parameter except for a positive association with diastolic blood pressure for high intake of 'fruits-vegetables-sweets-snacks' pattern.

CONCLUSION

Our results indicate positive associations of the 'animal food' pattern with cardio-metabolic risk factors in India. Further longitudinal assessments of dietary patterns in India are required to validate the findings.

Single nucleotide polymorphisms as markers of genetic susceptibility for oral potentially malignant disorders risk: Review of evidence to date

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We reviewed single nucleotide polymorphisms for oral pre-cancer susceptibility.

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All of them were pathway based candidate gene association studies.

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The current level of evidence is very limited.

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Integrated characterization of germline/somatic alterations in oral cancer & pre-cancer is needed.

Background

Oral cancers are preceded by oral potentially malignant disorders (OPMD). Understanding genetic susceptibility for OPMD risk could provide an opportunity for risk assessment of oral cancer through early disease course. We conducted a review of single nucleotide polymorphism (SNP) studies for OPMD risk.

Methods

We identified all relevant studies examining associations of SNPs with OPMD (leukoplakia, erythroplakia and oral sub-mucous fibrosis) conducted world-wide between January, 2000 and February, 2016 using a combined keyword search on PubMed. Of these, 47 studies that presented results as odds ratios and 95% CI were considered for full review.

Results

The majority of eligible studies that explored candidate gene associations for OPMD were small (N < 200 cases), limiting their scope to provide strong inference for any SNP identified to date in any population. Commonly studied SNPs were genes of carcinogen metabolism (n = 18 studies), DNA repair (n = 11 studies), cell cycle control (n = 8 studies), extra-cellular matrix alteration (n = 8 studies) and immune-inflammatory (n = 6 studies) pathways. Based on significant associations as reported by two or more studies, suggestive markers included SNPs in GSTM1 (null), CCND1 (G870A), MMP3 (-1171; promotor region), TNFα (-308; rs800629), XPD (codon 751) and Gemin3 (rs197412) as well as in p53 (codon 72) in Indian populations. However, an equal or greater number of studies reported null or mixed associations for SNPs in GSTM1 (null), p53 (codon 72), XPD (codon 751), XRCC (rs25487 C/T), GSTT1 (null) and CYP1A1m1 (MspI site).

Conclusion

Candidate gene association studies have not yielded consistent data on risk loci for OPMD. High-throughput genotyping approaches for OPMD, with concurrent efforts for oral cancer, could prove useful in identifying robust risk-loci to help understand early disease course susceptibility for oral cancer.

Quasiparticle Breakdown and Spin Hamiltonian of the Frustrated Quantum Pyrochlore Yb_{2}Ti_{2}O_{7} in a Magnetic Field

The frustrated pyrochlore magnet Yb_{2}Ti_{2}O_{7} has the remarkable property that it orders magnetically but has no propagating magnons over wide regions of the Brillouin zone. Here we use inelastic neutron scattering to follow how the spectrum evolves in cubic-axis magnetic fields. At high fields we observe, in addition to dispersive magnons, a two-magnon continuum, which grows in intensity upon reducing the field and overlaps with the one-magnon states at intermediate fields leading to strong renormalization of the dispersion relations, and magnon decays. Using heat capacity measurements we find that the low- and high-field regions are smoothly connected with no sharp phase transition, with the spin gap increasing monotonically in field. Through fits to an extensive data set of dispersion relations combined with magnetization measurements, we reevaluate the spin Hamiltonian, finding dominant quantum exchange terms, which we propose are responsible for the anomalously strong fluctuations and quasiparticle breakdown effects observed at low fields.

Screening for Atrial Fibrillation

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Doping Dependence of Collective Spin and Orbital Excitations in the Spin-1 Quantum Antiferromagnet La_{2-x}Sr_{x}NiO_{4} Observed by X Rays

We report the first empirical demonstration that resonant inelastic x-ray scattering (RIXS) is sensitive to collective magnetic excitations in S=1 systems by probing the Ni L_{3} edge of La_{2-x}Sr_{x}NiO_{4} (x=0, 0.33, 0.45). The magnetic excitation peak is asymmetric, indicating the presence of single and multi-spin-flip excitations. As the hole doping level is increased, the zone boundary magnon energy is suppressed at a much larger rate than that in hole doped cuprates. Based on the analysis of the orbital and charge excitations observed by RIXS, we argue that this difference is related to the orbital character of the doped holes in these two families. This work establishes RIXS as a probe of fundamental magnetic interactions in nickelates opening the way towards studies of heterostructures and ultrafast pump-probe experiments.

Conversion of gestational diabetes mellitus to future Type 2 diabetes mellitus and the predictive value of HbA1c in an Indian cohort

AIM

To investigate the distribution of and risk factors for dysglycaemia (Type 2 diabetes and prediabetes) in women with previous gestational diabetes mellitus in India.

METHODS

All women (n = 989) from two obstetric units in New Delhi and Hyderabad with a history of gestational diabetes were invited to participate, of whom 366 (37%) agreed. Sociodemographic, medical and anthropometric data were collected and 75-g oral glucose tolerance test were carried out.

RESULTS

Within 5 years (median 14 months) of the pregnancy in which they were diagnosed with gestational diabetes, 263 (72%) women were dysglycaemic, including 119 (32%) and 144 (40%) with Type 2 diabetes and prediabetes, respectively. A higher BMI [odds ratio 1.16 per 1-kg/m² greater BMI (95% CI 1.10, 1.28)], presence of acanthosis nigricans [odds ratio 3.10, 95% CI (1.64, 5.87)], postpartum screening interval [odds ratio 1.02 per 1 month greater screening interval 95% CI (1.01, 1.04)] and age [odds ratio 1.10 per 1-year older age 95% CI (1.04, 1.16)] had a higher likelihood of having dysglycaemia. The American Diabetes Association-recommended threshold HbA_1c value of ≥ 48 mmol/mol (6.5%) had a sensitivity and specificity of 81.4 and 90.7%, respectively, for determining the presence of Type 2 diabetes postpartum.

CONCLUSION

The high post-pregnancy conversion rates of gestational diabetes to diabetes reported in the present study reinforce the need for mandatory postpartum screening and identification of strategies for preventing progression to Type 2 diabetes. Use of the American Diabetes Association-recommended HbA_1c threshold for diabetes may lead to significant under-diagnosis.

Hall effect in charged conducting ferroelectric domain walls

Enhanced conductivity at specific domain walls in ferroelectrics is now an established phenomenon. Surprisingly, however, little is known about the most fundamental aspects of conduction. Carrier types, densities and mobilities have not been determined and transport mechanisms are still a matter of guesswork. Here we demonstrate that intermittent-contact atomic force microscopy (AFM) can detect the Hall effect in conducting domain walls. Studying YbMnO₃ single crystals, we have confirmed that p-type conduction occurs in tail-to-tail charged domain walls. By calibration of the AFM signal, an upper estimate of ∼1 × 10¹⁶ cm⁻³ is calculated for the mobile carrier density in the wall, around four orders of magnitude below that required for complete screening of the polar discontinuity. A carrier mobility of∼50 cm²V⁻¹s⁻¹ is calculated, about an order of magnitude below equivalent carrier mobilities in p-type silicon, but sufficiently high to preclude carrier-lattice coupling associated with small polarons.

Conduction in ferroelectric domain walls is now an established phenomenon, yet fundamental aspects of transport physics remain elusive. Here, Campbell et al. report the type, density and mobility of carriers in conducting domain walls in ytterbium manganite using nanoscale Hall effect measurements.

Synthesis of Mesoporous Silica Monoliths — A Novel Approach Towards Fabrication of Solid-State Optical Sensors for Environmental Applications

Mesoporous silica monoliths are an attractive area of research owing to their high specific surface area, uniform channels and mesoporous size (2–30[Formula: see text]nm). This paper deals with the direct templating synthesis of a mesoporous worm-like silica monolithic material using F127 — a triblock copolymer, by micro-emulsion technique using trimethyl benzene (TMB), as the solvent. The synthesized silica monolith is characterized using SEM-EDAX, XRD, BET, NMR and FT-IR. The monolith shows an ordered worm-like mesoporous structure with tuneable through pores, an excellent host for the anchoring of chromo-ionophores for the naked-eye metal ion-sensing. The mesoporous monoliths were loaded with 4-dodecyl-6-(2-pyridylazo)-phenol (DPAP) ligand through direct immobilization, thereby acting as solid-state naked-eye colorimetric ion-sensors for the sensing toxic Pb[Formula: see text] ions at parts-per-billion (ppb) level in various industrial and environmental systems. The influence of various experimental parameters such as solution pH, limiting ligand loading concentration, amount of monolith material, matrix tolerance level, limit of detection and quantification has been studied and optimized.

Maternal antecedents of adiposity and studying the transgenerational role of hyperglycemia and insulin (MAASTHI): a prospective cohort study : Protocol of birth cohort at Bangalore, India

BACKGROUND

India is experiencing an epidemic of obesity-hyperglycaemia, which coincides with child bearing age for women. The epidemic can be sustained and augmented through transgenerational transmission of adiposity and glucose intolerance in women. This presents an opportunity for exploring a clear strategy for the control of this epidemic in India. We conducted a study between November 2013 and May 2015 to inform the design of a large pregnancy cohort study. Based on the findings of this pilot, we developed the protocol for the proposed birth cohort of 5000 women, the recruitment for which will start in April 2016. The protocol of the study documents the processes which aim at advancing the available knowledge, linking several steps in the evolution of obesity led hyperglycemia.

METHODS

Maternal Antecedents of Adiposity and Studying the Transgenerational role of Hyperglycemia and Insulin (MAASTHI) is a cohort study in the public health facilities in Bangalore, India. The objective of MAASTHI is to prospectively assess the effects of glucose levels in pregnancy on the risk of adverse infant outcomes, especially in predicting the possible risk markers of later chronic diseases. The primary objective of the proposed study is to investigate the effect of glucose levels in pregnancy on skinfold thickness (adiposity) in infancy as a marker of future obesity and diabetes in offspring. The secondary objective is to assess the association between psychosocial environment of mothers and adverse neonatal outcomes including adiposity. The study aims to recruit 5000 pregnant women and follow them and their offspring for a period of 4 years. The institutional review board at The Indian Institute of Public Health (IIPH)-H, Bangalore, Public Health Foundation of India has approved the protocol. All participants are required to provide written informed consent.

DISCUSSION

The findings from this study may help to address important questions on screening and management of high blood sugar in pregnancy. It may provide critical information on the specific determinants driving the underweight-obesity-T2DM epidemic in India. The study can inform the policy regarding the potential impact of screening and management protocols in public healthcare facilities. The public health implications include prioritising issues of maternal glycemic control and weight management and better understanding of the lifecourse determinants in the development of T2DM.