Rhabdomyolysis and fluctuating asymptomatic hyperCKemia associated with CACNA1S variant

BACKGROUND AND PURPOSE

CACNA1S encodes Ca_v 1.1, a voltage sensor for muscle excitation-contraction coupling, which activates the ryanodine receptor 1 (RYR1) leading to calcium release from the sarcoplasmic reticulum. CACNA1S mutations cause hypokalemic periodic paralysis, malignant hyperthermia and congenital myopathy. RYR1 mutations result in congenital myopathy, malignant hyperthermia and rhabdomyolysis.

METHODS

The aim was to describe a novel phenotype associated with a CACNA1S variant at a site previously linked to hypokalemic periodic paralysis.

RESULTS

The patient presented with fluctuating asymptomatic creatine kinase elevation after an episode of rhabdomyolysis but has no history of periodic paralysis. His muscle biopsy showed core-like structures occurring mainly in type 2 fibers. He carries a novel Ca_v 1.1 variant (p.Arg528Leu) affecting a highly conserved amino acid. Different mutations at the same location cause hypokalemic periodic paralysis.

CONCLUSION

This case underscores the similarity between the phenotypes caused by mutations in two functionally linked proteins, RYR1 and Ca_v 1.1.

An investigation of routes to cancer diagnosis in 10 international jurisdictions, as part of the International Cancer Benchmarking Partnership: survey development and implementation

OBJECTIVES

This paper describes the methods used in the International Cancer Benchmarking Partnership Module 4 Survey (ICBPM4) which examines time intervals and routes to cancer diagnosis in 10 jurisdictions. We present the study design with defining and measuring time intervals, identifying patients with cancer, questionnaire development, data management and analyses.

DESIGN AND SETTING

Recruitment of participants to the ICBPM4 survey is based on cancer registries in each jurisdiction. Questionnaires draw on previous instruments and have been through a process of cognitive testing and piloting in three jurisdictions followed by standardised translation and adaptation. Data analysis focuses on comparing differences in time intervals and routes to diagnosis in the jurisdictions.

PARTICIPANTS

Our target is 200 patients with symptomatic breast, lung, colorectal and ovarian cancer in each jurisdiction. Patients are approached directly or via their primary care physician (PCP). Patients' PCPs and cancer treatment specialists (CTSs) are surveyed, and 'data rules' are applied to combine and reconcile conflicting information. Where CTS information is unavailable, audit information is sought from treatment records and databases.

MAIN OUTCOMES

Reliability testing of the patient questionnaire showed that agreement was complete (κ=1) in four items and substantial (κ=0.8, 95% CI 0.333 to 1) in one item. The identification of eligible patients is sufficient to meet the targets for breast, lung and colorectal cancer. Initial patient and PCP survey response rates from the UK and Sweden are comparable with similar published surveys. Data collection was completed in early 2016 for all cancer types.

CONCLUSION

An international questionnaire-based survey of patients with cancer, PCPs and CTSs has been developed and launched in 10 jurisdictions. ICBPM4 will help to further understand international differences in cancer survival by comparing time intervals and routes to cancer diagnosis.

Effect of oxygen plasma immersion ion implantation on the formation of nanostructures over Ni–Ti alloy

Ni–Ti alloy has been implanted with oxygen ions by plasma immersion ion implantation. Ni–Ti–O nanotubes are formed by anodic oxidation of oxygen implanted Ni–Ti alloy.

Luminescence and high temperature ferromagnetism in YAlO nanophosphors: materials for efficient next generation LEDs and spintronic applications

Yttrium-aluminium-oxide (YAlO) based nanophosphors for environment friendly and efficient white LEDs and spintronics devices.

Corrosion behaviour of tetrahedral amorphous carbon (ta-C) filled titania nano tubes

3D images of nanotube (a) TNT and ta-C filled TNT samples at (b) 0.5 min, (c) 1 min, (d) 2 min, (e) 5 min and (f) 10 min.

Effect of plasma nitriding on structure and biocompatibility of self-organised TiO2 nanotubes on Ti–6Al–7Nb

TiO₂ nanotubes formed by anodic oxidation of Ti–6Al–7Nb were nitrided in a nitrogen plasma.

Formation of a protective nitride layer by electrochemical nitridation on 316L SS bipolar plates for a proton exchange membrane fuel cell (PEMFC)

In the present study, an attempt has been made to increase the corrosion resistance of 316L stainless steel (SS) bipolar plates (Bp) through electrochemical nitridation using a nitrate bearing electrolyte solution of 0.1 M HNO₃ and 0.5 M KNO_3.

Investigating the association between obesity and asthma in 6- to 8-year-old Saudi children: a matched case-control study

BACKGROUND

Previous studies have demonstrated an association between obesity and asthma, but there remains considerable uncertainty about whether this reflects an underlying causal relationship.

AIMS

To investigate the association between obesity and asthma in pre-pubertal children and to investigate the roles of airway obstruction and atopy as possible causal mechanisms.

METHODS

We conducted an age- and sex-matched case-control study of 1,264 6- to 8-year-old schoolchildren with and without asthma recruited from 37 randomly selected schools in Madinah, Saudi Arabia. The body mass index (BMI), waist circumference and skin fold thickness of the 632 children with asthma were compared with those of the 632 control children without asthma. Associations between obesity and asthma, adjusted for other potential risk factors, were assessed separately in boys and girls using conditional logistic regression analysis. The possible mediating roles of atopy and airway obstruction were studied by investigating the impact of incorporating data on sensitisation to common aeroallergens and measurements of lung function.

RESULTS

BMI was associated with asthma in boys (odds ratio (OR)=1.14, 95% confidence interval (CI), 1.08-1.20; adjusted OR=1.11, 95% CI, 1.03-1.19) and girls (OR=1.37, 95% CI, 1.26-1.50; adjusted OR=1.38, 95% CI, 1.23-1.56). Adjusting for forced expiratory volume in 1 s had a negligible impact on these associations, but these were attenuated following adjustment for allergic sensitisation, particularly in girls (girls: OR=1.25; 95% CI, 0.96-1.60; boys: OR=1.09, 95% CI, 0.99-1.19).

CONCLUSIONS

BMI is associated with asthma in pre-pubertal Saudi boys and girls; this effect does not appear to be mediated through respiratory obstruction, but in girls this may at least partially be mediated through increased risk of allergic sensitisation.

Response surface modeling for optimization heterocatalytic Fenton oxidation of persistence organic pollution in high total dissolved solid containing wastewater

The rice-husk-based mesoporous activated carbon (MAC) used in this study was precarbonized and activated using phosphoric acid. N2 adsorption/desorption isotherm, X-ray powder diffraction, electron spin resonance, X-ray photoelectron spectroscopy and scanning electron microscopy, transmission electron microscopy, (29)Si-NMR spectroscopy, and diffuse reflectance spectroscopy were used to characterize the MAC. The tannery wastewater carrying high total dissolved solids (TDS) discharged from leather industry lacks biodegradability despite the presence of dissolved protein. This paper demonstrates the application of free electron-rich MAC as heterogeneous catalyst along with Fenton reagent for the oxidation of persistence organic compounds in high TDS wastewater. The heterogeneous Fenton oxidation of the pretreated wastewater at optimum pH (3.5), H2O2 (4 mmol/L), FeSO4[Symbol: see text]7H2O (0.2 mmol/L), and time (4 h) removed chemical oxygen demand, biochemical oxygen demand, total organic carbon and dissolved protein by 86, 91, 83, and 90%, respectively.

Development and characterization of coaxially electrospun gelatin coated poly (3-hydroxybutyric acid) thin films as potential scaffolds for skin regeneration

The morphology of fibers synthesized through electrospinning has been found to mimic extracellular matrix. Coaxially electrospun fibers of gelatin (sheath) coated poly (3-hydroxybutyric acid) (PHB) (core) was developed using 2,2,2 trifluoroethanol(TFE) and 1,1,1,3,3,3 hexafluoro-2-propanol(HFIP) as solvents respectively. The coaxial structure and coating of gelatin with PHB fibers was confirmed through transmission electron microscopy (TEM), scanning electron microscopy (SEM) and X-ray photoelectron spectroscopy (XPS). Thermal stability of the coaxially electrospun fibers was analyzed using thermogravimetric analysis(TGA), differential scanning calorimetry(DSC) and differential thermogravimetric analysis(DTA). Complete evaporation of solvent and gelatin grafting over PHB fibers was confirmed through attenuated total reflection-Fourier transformed infrared spectroscopy (ATR-FTIR). The coaxially electrospun fibers exhibited competent tensile properties for skin regeneration with high surface area and porosity. In vitro degradation studies proved the stability of fibers and its potential applications in tissue engineering. The fibers supported the growth of human dermal fibroblasts and keratinocytes with normal morphology indicating its potential as a scaffold for skin regeneration.

Investigation of electrochemical behavior of nitrogen implanted Ti-15Mo-3Nb-3Al alloy in Hank's solution

Titanium alloy Ti-15-3-3 (Beta-21S) was implanted with nitrogen ions by plasma immersion ion implantation at 700, 750 and 800 °C. Micro Raman and XPS results confirm the formation of nitrides after implantation. Corrosion current density (icorr) of the treated samples in simulated body fluid (Hank's solution) is higher than that of the substrate. Treated samples also exhibit lower charge transfer resistance and higher double layer capacitance as compared to that of substrate in electrochemical impedance spectroscopic studies. However, no corrosion related effects are observed after 28 days of immersion in SBF. EDS results show the presence of oxygen after corrosion studies. XPS spectra from the implanted samples show the presence of nitride and oxynitride on the surface and formation of oxide due to corrosion process.

Protocol for a systematic review and individual patient data meta-analysis of prognostic factors of foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS)

Background

Diabetes–related lower limb amputations are associated with considerable morbidity and mortality and are usually preceded by foot ulceration. The available systematic reviews of aggregate data are compromised because the primary studies report both adjusted and unadjusted estimates. As adjusted meta-analyses of aggregate data can be challenging, the best way to standardise the analytical approach is to conduct a meta-analysis based on individual patient data (IPD).

There are however many challenges and fundamental methodological omissions are common; protocols are rare and the assessment of the risk of bias arising from the conduct of individual studies is frequently not performed, largely because of the absence of widely agreed criteria for assessing the risk of bias in this type of review. In this protocol we propose key methodological approaches to underpin our IPD systematic review of prognostic factors of foot ulceration in diabetes.

Review questions;

1. What are the most highly prognostic factors for foot ulceration (i.e. symptoms, signs, diagnostic tests) in people with diabetes?

2. Can the data from each study be adjusted for a consistent set of adjustment factors?

3. Does the model accuracy change when patient populations are stratified according to demographic and/or clinical characteristics?

Methods

MEDLINE and EMBASE databases from their inception until early 2012 were searched and the corresponding authors of all eligible primary studies invited to contribute their raw data. We developed relevant quality assurance items likely to identify occasions when study validity may have been compromised from several sources. A confidentiality agreement, arrangements for communication and reporting as well as ethical and governance considerations are explained.

We have agreement from the corresponding authors of all studies which meet the eligibility criteria and they collectively possess data from more than 17000 patients. We propose, as a provisional analysis plan, to use a multi-level mixed model, using “study” as one of the levels. Such a model can also allow for the within-patient clustering that occurs if a patient contributes data from both feet, although to aid interpretation, we prefer to use patients rather than feet as the unit of analysis. We intend to only attempt this analysis if the results of the investigation of heterogeneity do not rule it out and the model diagnostics are acceptable.

Discussion

This review is central to the development of a global evidence-based strategy for the risk assessment of the foot in patients with diabetes, ensuring future recommendations are valid and can reliably inform international clinical guidelines.

Computer-assisted history-taking systems (CAHTS) in health care: benefits, risks and potential for further development

BACKGROUND

A computer-assisted history-taking system (CAHTS) is a tool that aids clinicians in gathering data from patients to inform a diagnosis or treatment plan. Despite the many possible applications and even though CAHTS have been available for nearly three decades, these remain underused in routine clinical practice.

OBJECTIVE

Through an interpretative review of the literature, we provide an overview of the field of CAHTS, which also offers an understanding of the impact of these systems on policy, practice and research.

METHODS

We conducted a search and critique of the literature on CAHTS. Using a comprehensive set of terms, we searched: MEDLINE, EMBASE, The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, The Cochrane Central Register of Controlled Trials, The Cochrane Methodology Register, Health Technology Assessment Database and the NHS Economic Evaluation Database over a ten-year period (January 1997 to May 2007) to identify systematic reviews, technical reports and health technology assessments, and randomised controlled trials.

RESULTS

The systematic review of the literature suggests that CAHTS can save professionals' time, improve delivery of care to those with special needs and also facilitate the collection of information, especially potentially sensitive information (e.g. sexual history, alcohol consumption). The use of CAHTS also has disadvantages that impede the process of history taking and may pose risks to patients. CAHTS are inherently limited when detecting non-verbal communication, may pose irrelevant questions and frustrate the users with technical problems. Our review suggests that barriers such as a preference for pen-and-paper methods and concerns about data loss and security still exist and affect the adoption of CAHTS. In terms of policy and practice, CAHTS make input of data from disparate sites possible, which facilitates work from disparate sites and the collection of data for nationwide screening programmes such as the vascular risk assessment programme for people aged 40-74, now starting in England.

CONCLUSIONS

Our review shows that for CAHTS to be adopted in mainstream health care, important changes should take place in how we conceive, plan and conduct primary and secondary research on the topic so that we provide the framework for a comprehensive evaluation that will lead to an evidence base to inform policy and practice.

Predicting language change between 3 and 5 years and its implications for early identification

BACKGROUND AND OBJECTIVE

Early language delays across the preschool period have important implications for children, parents, and services raising the significance of early identification. Screening tests are an appealing solution but have proved problematic. A combined risk model would seem promising but has yet to be tested. The goal of this study was to examine the factors that predict language change in a nationally representative sample of children between 3 and 5 years when most children are identified as being in need of services.

METHODS

By using data from children (n = 13,016) in the Millennium Cohort Study (a national UK birth cohort), linear regression was used to predict 5-year performance from 3-year test performance data coupled with sociodemographic and within-child factors and indicators of parental concern. Patterns of change were identified and logistic regression was used to predict the difference between children for whom profiles change and those for whom they do not.

RESULTS

The final model (predicting 32% of the variance) included maternal education, pattern construction, behavior, language concerns, and 3-year vocabulary. Four change patterns were identified: one consistently low (n = 201), one consistently high (n = 12,066), a group that is resilient (n = 572), and one with a declining profile (n = 177). The models accurately predicted 71% of the declining group and 99% of the resilient group. Maternal education (odds ratio: 0.49) and behavior (odds ratio: 0.9) were significant predictors for the former and maternal education (odds ratio: 0.6) and pattern construction (odds ratio: 1.03) the latter.

CONCLUSIONS

Early identification of delayed language remains problematic but, once identified, there are key indicators that predict which children are likely to be more or less at risk across time. The implications are discussed in terms of policy and practice.

Prevalence of allergic disorders among primary school-aged children in Madinah, Saudi Arabia: two-stage cross-sectional survey

BACKGROUND

There are limited data on the epidemiology of allergic disorders in Saudi Arabia. Such data are needed for, amongst other things, helping to plan service provision at a time when there is considerable investment taking place in national healthcare development. We sought to estimate the prevalence of atopic eczema, allergic rhinitis and asthma in primary school children in Madinah, Saudi Arabia.

METHODS AND FINDINGS

We conducted a two-stage cross-sectional survey of schoolchildren in Madinah. Children were recruited from 38 randomly selected schools. Questionnaires were sent to the parents of all 6,139 6-8 year old children in these schools. These parental-completed questionnaires incorporated questions from the International Study of Asthma and Allergies in Childhood (ISAAC), which had previously been validated for use in Arab populations. We undertook descriptive analyses, using the Generalized Estimating Equation (GEE) to calculate 95% confidence intervals. The overall response rate was 85.9% (n = 5,188), 84.6% for girls and 86.2% for boys, respectively. Overall, parents reported symptoms suggestive of a history of eczema in 10.3% (95%CI 9.4, 11.4), rhinitis in 24.2% (95%CI 22.3, 26.2) and asthma in 23.6% (95%CI 21.3, 26.0) of children. Overall, 41.7% (95%CI 39.1, 44.4) of children had symptoms suggestive of at least one allergic disorder, with a substantial minority manifesting symptoms indicative of co-morbid allergic disease. Comparison of these symptom-based prevalence estimates with reports of clinician-diagnosed disease suggested that the majority of children with eczema and asthma had been diagnosed, but only a minority (17.4%) of children had been diagnosed with rhinitis. International comparisons indicated that children in Madinah have amongst the highest prevalence of allergic problems in the world.

CONCLUSIONS

Symptoms indicative of allergic disease are very common in primary school-aged children in Madinah, Saudi Arabia, with figures comparable to the highest risk regions in the world.

Avoiding Inappropriate Invitations to Cancer Screening Programmes: The Role of Primary Care

Objectives

To examine current procedures for cancer screening invitation list (SIL) checking in primary care, and to make recommendations for the future use of these procedures.

Setting

Cancer screening departments/units and associated general practices across England.

Methods

1) An analysis of the outputs of screening programme SIL checking, and accompanying practice questionnaire, for cancers of the cervix (9 screening centres, 36 general practices), breast (6 centres, 76 practices) and bowel (pilot hub, 7 practices)-supplemented by an audit of calls to screening centres to identify inappropriate invitations; 2) a national postal questionnaire survey sent to all 80 breast screening departments across England and 320 associated general practices; 3) telephone interviews with 13 NHS screening staff to obtain detailed perspectives about SIL checking procedures.

Results

SIL checking in primary care is undertaken by a variety of clinical and non-clinical staff. It plays a useful role in cervical screening with tangible evidence of refinements to the SIL and support from both primary care and screening centre staff. Conversely, its role in breast and bowel screening is not supported by the results of this study. Overall, there is no significant evidence of adverse effects from inappropriate invitations.

Conclusions

SIL checking in primary care for cervical cancer should continue, but its use in breast and bowel cancer screening is not supported by our results. New ways of undertaking the SIL checking process to make it more accurate and less burdensome should be examined.

The impact of eHealth on the quality and safety of health care: a systematic overview

BACKGROUND

There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care.

METHODS AND FINDINGS

We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.

CONCLUSIONS

There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and "techno-enthusiasts" as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.

Is the prevalence of asthma declining? Systematic review of epidemiological studies

Asthma prevalence has increased very considerably in recent decades such that it is now one of the commonest chronic disorders in the world. Recent evidence from epidemiological studies, however, suggests that the prevalence of asthma may now be declining in many parts of the world, which, if true is important for health service planning and also because this offers the possibility of generating and testing new aetiological hypotheses. Our objective was to determine whether the prevalence of asthma is declining worldwide. We undertook a systematic search of EMBASE, Medline, Web of Science and Google Scholar, for high quality reports of cohort studies, repeat cross-sectional studies and analyses of routine healthcare datasets to examine international trends in asthma prevalence in children and adults for the period 1990-2008. There were 48 full reports of studies that satisfied our inclusion criteria. The large volume of data identified clearly indicate that there are, at present, no overall signs of a declining trend in asthma prevalence; on the contrary, asthma prevalence is in many parts of the world still increasing. The reductions in emergency healthcare utilization being reported in some economically developed countries most probably reflect improvements in quality of care. There remain major gaps in the literature on asthma trends in relation to Africa and parts of Asia. There is no overall global downward trend in the prevalence of asthma. Healthcare planners will for the foreseeable future, therefore, need to continue with high levels of anticipated expenditure in relation to provision of asthma care.

Epidemiology and disease burden from allergic disease in Scotland: analyses of national databases

BACKGROUND

There are ongoing concerns about the quality of care provided to patients with allergic disorders in Scotland, but there are relatively few reliable data on the overall disease burden. We sought to: (1) describe the incidence, prevalence and outcome of allergic disorders; (2) estimate healthcare burden and costs; and (3) investigate ethnic variations in the epidemiology and outcomes from allergic disorders in Scotland.

METHODS

DATA SOURCES

national surveys; primary care data; prescribing and medication data; hospital admissions data and mortality data.

RESULTS

Allergic disorders are extremely common in Scotland, affecting about one in three of the population at some time in their lives. Incidence was highest for eczema (10.2 per 1000 registered patients). Over 4% of all GP consultations and 1.5% of hospital admissions were for allergic disorders. There were 100 asthma deaths in 2005 (20 per million people). Direct healthcare costs for allergic disorders were an estimated pound130 million per year, the majority of these being incurred in primary care and related to asthma.

CONCLUSIONS

Allergic disorders are common in Scotland and given the very high proportion of children now affected, the high disease burden associated with these conditions is likely to persist for many decades.

Omega 3 and 6 oils for primary prevention of allergic disease: systematic review and meta-analysis

BACKGROUND

There is conflicting evidence on the use of omega 3 and omega 6 supplementation for the prevention of allergic diseases. We conducted a systematic review evaluating the effectiveness of omega 3 and 6 oils for the primary prevention of sensitization and development of allergic disorders.

METHODS

We searched The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS, PsycInfo, AMED, ISI Web of Science and Google Scholar for double-blind randomized controlled trials. Two authors independently assessed articles for inclusion. Meta-analyses were undertaken using fixed effects modelling, or random effects modelling in the event of detecting significant heterogeneity.

RESULTS

Of the 3129 articles identified, 10 reports (representing six unique studies) satisfied the inclusion criteria. Four studies compared omega 3 supplements with placebo and two studies compared omega 6 supplements with placebo. There was no clear evidence of benefit in relation to reduced risk of allergic sensitization or a favourable immunological profile. Meta-analyses failed to identify any consistent or clear benefits associated with use of omega 3 [atopic eczema: RR = 1.10 (95% CI 0.78-1.54); asthma: RR = 0.81 (95% CI 0.53-1.25); allergic rhinitis: RR = 0.80 (95% CI 0.34-1.89) or food allergy RR = 0.51 (95% CI 0.10-2.55)] or omega 6 oils [atopic eczema: RR = 0.80 (95% CI 0.56-1.16)] for the prevention of clinical disease.

CONCLUSIONS

Contrary to the evidence from basic science and epidemiological studies, our systematic review and meta-analysis suggests that supplementation with omega 3 and omega 6 oils is probably unlikely to play an important role as a strategy for the primary prevention of sensitization or allergic disease.

Will Systematized Nomenclature of Medicine-Clinical Terms improve our understanding of the disease burden posed by allergic disorders?

Analysis of data collected through the use of high-quality computerized systems is vital if we are to understand the health burden from allergic disease. Coding systems currently used, such as the World Health Organization's International Classification of Diseases and the Read system, have however been criticized as being unduly restrictive and hence inadequate for the detailed coding of allergic problems. Greater granularity of coding can be achieved by using the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) system, which will be adopted by several countries including the United States and United Kingdom. Before the introduction of SNOMED-CT, it is important that several issues are resolved, including ensuring that adequate mapping occurs from existing systems, that the SNOMED-CT is trialled before general implementation, and that training is provided for users new to coding as part of their clinical practice. Of particular importance is that the allergy fraternity bring to light any gaps in allergy coding through the creation of a working group to advise the newly formed International Healthcare Terminology Standards Development Organisation. There is also a role for allergy experts, working in conjunction with government agencies and professional bodies, to determine a recommended set of codes, which will obviate some of the inevitable challenges raised by a very fluid coding structure for those wishing to undertake secondary analysis of health care datasets.

Exploiting the potential of routine data to better understand the disease burden posed by allergic disorders

The Department of Health and Scottish Executive are currently undertaking independent reviews of allergy services in England (and Wales) and Scotland. Each review will assess the disease burden posed by allergic problems, involving secondary analyses of routine National Health Service (NHS) datasets. Major suggestions for re-structuring and/or re-focusing the NHS efforts to better deal with allergic disease are anticipated. The UK has some of the best datasets of routine health data in the world, but despite their strengths, they have important limitations. These include gaps in data collection, particularly in relation to monitoring of Accident & Emergency and out-patient consultations, and in-patient prescribing, thereby resulting in considerable under-estimates of hospital workload. The current gaps in service monitoring are likely to under-estimate the burden and workload associated with allergic problems, particularly in secondary care. One major limitation of existing data sources is the general inability to link individual patient level data between different datasets. By unlocking this potential there are very considerable potential gains to be made. Data linkage techniques currently being developed in the UK offer exciting new possibilities of looking across the primary-, secondary- and tertiary-care interfaces and also assessing short-and long-term social and educational outcomes in relation to allergic disorders. The current reviews of allergy services being undertaken need to be cognisant of these inherent limitations of existing data sources and would do well to recommend strategic initiatives that could enhance the availability, accessibility and quality of these datasets. Ideally, this should include investment in central data repositories staffed by teams with the necessary technical and statistical expertise, which would also take responsibility for progressing data linkage capabilities.