Data quality and patient characteristics in European ANCA-associated vasculitis registries: data retrieval by federated querying

OBJECTIVES

This study aims to describe the data structure and harmonisation process, explore data quality and define characteristics, treatment, and outcomes of patients across six federated antineutrophil cytoplasmic antibody-associated vasculitis (AAV) registries.

METHODS

Through creation of the vasculitis-specific Findable, Accessible, Interoperable, Reusable, VASCulitis ontology, we harmonised the registries and enabled semantic interoperability. We assessed data quality across the domains of uniqueness, consistency, completeness and correctness. Aggregated data were retrieved using the semantic query language SPARQL Protocol and Resource Description Framework Query Language (SPARQL) and outcome rates were assessed through random effects meta-analysis.

RESULTS

A total of 5282 cases of AAV were identified. Uniqueness and data-type consistency were 100% across all assessed variables. Completeness and correctness varied from 49%-100% to 60%-100%, respectively. There were 2754 (52.1%) cases classified as granulomatosis with polyangiitis (GPA), 1580 (29.9%) as microscopic polyangiitis and 937 (17.7%) as eosinophilic GPA. The pattern of organ involvement included: lung in 3281 (65.1%), ear-nose-throat in 2860 (56.7%) and kidney in 2534 (50.2%). Intravenous cyclophosphamide was used as remission induction therapy in 982 (50.7%), rituximab in 505 (17.7%) and pulsed intravenous glucocorticoid use was highly variable (11%-91%). Overall mortality and incidence rates of end-stage kidney disease were 28.8 (95% CI 19.7 to 42.2) and 24.8 (95% CI 19.7 to 31.1) per 1000 patient-years, respectively.

CONCLUSIONS

In the largest reported AAV cohort-study, we federated patient registries using semantic web technologies and highlighted concerns about data quality. The comparison of patient characteristics, treatment and outcomes was hampered by heterogeneous recruitment settings.

Daily opioid and stimulant co-use and nonfatal overdoses in the context of social disadvantage: Findings on marginalized populations

OBJECTIVE

Opioids and stimulants are increasingly implicated in overdose deaths, particularly among minoritized groups. We examined daily opioid and cocaine co-use, nonfatal overdoses, and naloxone carrying among minoritized people who inject drugs (PWID).

METHODS

The study derived data from 499 PWID in Baltimore City, MD, recruited using street-based outreach between 2016 and 2019. Participants reported overdoses; sociodemographic characteristics; and use of nonmedical prescription opioids, heroin, cocaine, and naloxone.

RESULTS

Among the participants, the mean age was 46, 34 % were female, 64 % self-identified as Black, and 53 % experienced recent homelessness. Black PWID, compared to White PWID, were as likely to use opioids and cocaine daily but were 61 % less likely to have naloxone. After controlling for sociodemographic characteristics, women (aOR:1.88, 95%CI: 1.14, 3.11), persons experiencing homelessness (aOR:3.07, 95%CI: 1.79, 5.24), and those who experienced a recent overdose (aOR:2.14, 95%CI: 1.29, 3.58) were significantly more likely to use opioids and any form of cocaine every day. In a subanalysis of only female PWID, females engaged in sex work (aOR:2.27, 95%CI: 1.02, 5.07) and females experiencing recent homelessness (aOR:5.82, 95%CI: 2.50, 13.52) were significantly more likely to use opioids and cocaine daily. Furthermore, females (aOR:1.69, 95%CI:1.03, 2.77), persons experiencing homelessness (aOR:1.94, 95%CI:1.16, 3.24), and those with higher educational attainment (aOR:2.06, 95%CI:1.09, 3.91) were more likely to often/always carry naloxone, while Black PWID were less likely to have naloxone (aOR:0.39, 95%CI:0.22, 0.69).

CONCLUSIONS

These findings highlight the need for targeted naloxone distribution and other harm-reduction interventions among minoritized groups in urban areas.

The association between ambient UVB dose and ANCA-associated vasculitis relapse and onset

Background

The aetiology of ANCA-associated vasculitis (AAV) and triggers of relapse are poorly understood. Vitamin D (vitD) is an important immunomodulator, potentially responsible for the observed latitudinal differences between granulomatous and non-granulomatous AAV phenotypes. A narrow ultraviolet B spectrum induces vitD synthesis (vitD-UVB) via the skin. We hypothesised that prolonged periods of low ambient UVB (and by extension vitD deficiency) are associated with the granulomatous form of the disease and an increased risk of AAV relapse.

Methods

Patients with AAV recruited to the Irish Rare Kidney Disease (RKD) (n = 439) and UKIVAS (n = 1961) registries were studied. Exposure variables comprised latitude and measures of ambient vitD-UVB, including cumulative weighted UVB dose (CW-D-UVB), a well-validated vitD proxy. An n-of-1 study design was used to examine the relapse risk using only the RKD dataset. Multi-level models and logistic regression were used to examine the effect of predictors on AAV relapse risk, phenotype and serotype.

Results

Residential latitude was positively correlated (OR 1.41, 95% CI 1.14–1.74, p = 0.002) and average vitD-UVB negatively correlated (0.82, 0.70–0.99, p = 0.04) with relapse risk, with a stronger effect when restricting to winter measurements (0.71, 0.57–0.89, p = 0.002). However, these associations were not restricted to granulomatous phenotypes. We observed no clear relationship between latitude, vitD-UVB or CW-D-UVB and AAV phenotype or serotype.

Conclusion

Our findings suggest that low winter ambient UVB and prolonged vitD status contribute to AAV relapse risk across all phenotypes. However, the development of a granulomatous phenotype does not appear to be directly vitD-mediated. Further research is needed to determine whether sufficient vitD status would reduce relapse propensity in AAV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02834-6.

Effect of Functional Rehabilitation on Performance of the Star Excursion Balance Test Among Recreational Athletes With Chronic Ankle Instability: A Systematic Review

OBJECTIVE

To determine (1) the effectiveness of rehabilitation for chronic ankle instability as measured by the Star Excursion Balance Test (SEBT) and (2) the relative efficacy and the long-term effects of these rehabilitation interventions.

DATA SOURCES

Ten electronic databases were searched (2009-2019).

STUDY SELECTION

Included articles were randomized controlled trials in English investigating recreational athletes aged ≥18 years with chronic ankle instability. At least 1 functional rehabilitation intervention had to be included and the SEBT test (or the modified version) used as an outcome measure.

DATA EXTRACTION

Two researchers (L.A., O.N.) extracted data regarding participant demographics; intervention characteristics; trial size; and results at baseline, postintervention, and at follow-up, where appropriate.

DATA SYNTHESIS

A systematic review and narrative synthesis was conducted. Methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool and the van Tulder scale. The review was registered with PROSPERO (ID: 164468). Ten studies (n=368), 2 high-quality, 1 moderate-quality, and 7 low-quality, were included in the review. Interventions included balance training, strength training, vibration training, and mixed training. Results suggest that rehabilitation of chronic ankle instability that includes wobble board exercises (average percentage change: 14.3%) and hip strengthening exercises (average percentage change: 12.8%) are most effective. Few studies compared different types of rehabilitation for chronic ankle instability. However, improvements on the SEBT suggest that a rehabilitation program focusing on wobble board training and hip strengthening performed 3 times weekly for 4-6 weeks is the optimal rehabilitation program to improve dynamic postural control in recreational athletes with chronic ankle instability.

CONCLUSIONS

Few studies directly compared different rehabilitation interventions, and there was limited long-term follow-up; therefore, the relative efficacy of different rehabilitation programs remains unclear. However, it seems that rehabilitation of chronic ankle instability should include proprioceptive and strengthening exercises of relatively short duration.

Study Protocol for DeCOmPRESS: Defining the Disease Course and Immune Profile of COVID-19 in the Immunosuppressed Patient

The ongoing coronavirus disease 2019 (COVID-19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Current advisory guidelines for high-risk groups—including people with autoimmune disease taking immunosuppressive therapies—are to take increased precautions and avoid any unnecessary contacts. The aim of the DeCOmPRESS study is to define the disease course and immune profile of COVID-19 in immunosuppressed patients. We will clinically phenotype patients with ANCA-associated vasculitis (AAV) who develop COVID-19 using a customized REDCap data collection instrument embedded within the Rare Kidney Disease (RKD) Biobank. This dataset will be interoperable with the rheum-COVID, Global Rheumatology Alliance, and SPRINT-SARI datasets, facilitating international data linkage. Acute and convalescent blood samples will be analysed by flow cytometry and ELISA to define the immunophenotype and cytokine profile. Patients will track COVID-19 and AAV symptoms through a bespoke smartphone app. DeCOmPRESS study findings will rapidly inform management of immunosuppressed patients who contract COVID-19 by defining the natural history and immunological manifestations of the disease in these patients. We will also determine whether pre-existing immunosuppressant therapy lessens the cytokine storm associated with severe COVID-19 disease, thereby paradoxically improving rather than worsening clinical outcomes. This protocol document details the procedures for end-to-end completion of the DeCOmPRESS project and is complemented by an associated comprehensive Study Manual (accessible at: https://www.tcd.ie/medicine/thkc/decompress/).

Introducing Critical Tiriti Policy Analysis: A new tool for anti-racism from Aotearoa New Zealand

Issue/problem

Te Tiriti o Waitangi (te Tiriti) was negotiated between the British Crown and Indigenous Māori in 1840. Māori understood the agreement as an affirmation of political authority and a guarantee of British protection. The Crown understood it as a cession of sovereignty. Te Tiriti places a mandatory obligation on the Crown to protect and promote Māori health that has not been upheld.

Description of the problem

Ethnic inequities in health outcomes have been allowed to flourish in Aotearoa. We explored to what extend te Tiriti could be a anti-racism tool that health policy could be usefully evaluated against?

Results

We introduce Critical Tiriti Analysis (CTA) a new form of critical policy analysis. CTA involves reviewing policy documents against the Preamble and the Articles of the Māori text of te Tiriti o Waitangi. The review process has five defined phases: i) orientation; ii) close reading; iii) determination; iv) strengthening practice; and v) Māori final word. We present a working example of CTA using the New Zealand Government’s Primary Health Care Strategy. This policy analysis found poor alignment with te Tiriti overall and the indicators of its implementation that we propose.

Lessons

This paper provides direction to public health practitioners wanting to improve Māori health outcomes and ensure Indigenous engagement, leadership and substantive authority in the policy process. It offers an approach to analysing policy that is simple to use and, inherently, a tool for advancing social justice.

Key messages

CTA is an anti-racism tool for holding the Crown accountable for Māori health. CTA could be adapted and applied in other colonial contexts to advance Indigenous health.

"Just-in-time" generation of datasets by considering structured representations of given consent for GDPR compliance

Data processing is increasingly becoming the subject of various policies and regulations, such as the European General Data Protection Regulation (GDPR) that came into effect in May 2018. One important aspect of GDPR is informed consent, which captures one's permission for using one's personal information for specific data processing purposes. Organizations must demonstrate that they comply with these policies. The fines that come with non-compliance are of such importance that it has driven research in facilitating compliance verification. The state-of-the-art primarily focuses on, for instance, the analysis of prescriptive models and posthoc analysis on logs to check whether data processing is compliant to GDPR. We argue that GDPR compliance can be facilitated by ensuring datasets used in processing activities are compliant with consent from the very start. The problem addressed in this paper is how we can generate datasets that comply with given consent "just-in-time". We propose RDF and OWL ontologies to represent the consent that an organization has collected and its relationship with data processing purposes. We use this ontology to annotate schemas, allowing us to generate declarative mappings that transform (relational) data into RDF driven by the annotations. We furthermore demonstrate how we can create compliant datasets by altering the results of the mapping. The use of RDF and OWL allows us to implement the entire process in a declarative manner using SPARQL. We have integrated all components in a service that furthermore captures provenance information for each step, further contributing to the transparency that is needed towards facilitating compliance verification. We demonstrate the approach with a synthetic dataset simulating users (re-)giving, withdrawing, and rejecting their consent on data processing purposes of systems. In summary, it is argued that the approach facilitates transparency and compliance verification from the start, reducing the need for posthoc compliance analysis common in the state-of-the-art.

Methods for Practising Ethics in Research and Innovation: A Literature Review, Critical Analysis and Recommendations

This paper provides a systematic literature review, analysis and discussion of methods that are proposed to practise ethics in research and innovation (R&I). Ethical considerations concerning the impacts of R&I are increasingly important, due to the quickening pace of technological innovation and the ubiquitous use of the outcomes of R&I processes in society. For this reason, several methods for practising ethics have been developed in different fields of R&I. The paper first of all presents a systematic search of academic sources that present and discuss such methods. Secondly, it provides a categorisation of these methods according to three main kinds: (1) ex ante methods, dealing with emerging technologies, (2) intra methods, dealing with technology design, and (3) ex post methods, dealing with ethical analysis of existing technologies. Thirdly, it discusses the methods by considering problems in the way they deal with the uncertainty of technological change, ethical technology design, the identification, analysis and resolving of ethical impacts of technologies and stakeholder participation. The results and discussion of our literature review are valuable for gaining an overview of the state of the art and serve as an outline of a future research agenda of methods for practising ethics in R&I.

Contributions of biogenic material to the atmospheric ice-nucleating particle population in North Western Europe

A minute fraction of atmospheric particles exert a disproportionate effect on the phase of mixed-phase clouds by acting as ice-nucleating particles (INPs). To understand the effects of these particles on weather and climate, both now and into the future, we must first develop a quantitative understanding of the major INP sources worldwide. Previous work has demonstrated that aerosols such as desert dusts are globally important INPs, but the role of biogenic INPs is unclear, with conflicting evidence for their importance. Here, we show that at a temperate site all INPs active above −18 °C at concentrations >0.1 L⁻¹ are destroyed on heating, consistent with these INPs being of biological origin. Furthermore, we show that a global model of desert dust INPs dramatically underestimates the measured INP concentrations, but is consistent with the thermally-stable component. Notably, the heat sensitive INPs are active at temperatures where shallow cloud layers in Northern Europe are frequently observed to glaciate. Hence, we suggest that biogenic material is important for primary ice production in this region. The prevalence of heat sensitive, most likely biogenic, INPs in this region highlights that, as a community, we need to quantify the sources and transport of these particles as well as determine their atmospheric abundance across the globe and at cloud altitudes.

Data linkage in medical science using the resource description framework: the AVERT model

There is an ongoing challenge as to how best manage and understand ‘big data’ in precision medicine settings. This paper describes the potential for a Linked Data approach, using a Resource Description Framework (RDF) model, to combine multiple datasets with temporal and spatial elements of varying dimensionality. This “AVERT model” provides a framework for converting multiple standalone files of various formats, from both clinical and environmental settings, into a single data source. This data source can thereafter be queried effectively, shared with outside parties, more easily understood by multiple stakeholders using standardized vocabularies, incorporating provenance metadata and supporting temporo-spatial reasoning. The approach has further advantages in terms of data sharing, security and subsequent analysis. We use a case study relating to anti-Glomerular Basement Membrane (GBM) disease, a rare autoimmune condition, to illustrate a technical proof of concept for the AVERT model.

Data linkage in medical science using the resource description framework: the AVERT model

There is an ongoing challenge as to how best manage and understand 'big data' in precision medicine settings. This paper describes the potential for a Linked Data approach, using a Resource Description Framework (RDF) model, to combine multiple datasets with temporal and spatial elements of varying dimensionality. This "AVERT model" provides a framework for converting multiple standalone files of various formats, from both clinical and environmental settings, into a single data source. This data source can thereafter be queried effectively, shared with outside parties, more easily understood by multiple stakeholders using standardized vocabularies, incorporating provenance metadata and supporting temporo-spatial reasoning. The approach has further advantages in terms of data sharing, security and subsequent analysis. We use a case study relating to anti-Glomerular Basement Membrane (GBM) disease, a rare autoimmune condition, to illustrate a technical proof of concept for the AVERT model.

Analysis of head impacts during sub-elite hurling practice sessions

The reported incidence of head and neck injuries in hurling is 0.12 per 1000 hours, but no previous research has quantified head impact characteristics in this sport. Here, a wireless accelerometer and gyroscope captured head impacts, in 20 senior club level hurling players. Peak linear and rotational acceleration and impact location were recorded during three hurling training sessions, each player participating once. A mean of 27.9 impacts (linear acceleration >10g) per player, per session were recorded; 1314 impacts during a total exposure time of 247 minutes. Only 2.6% impacts had peak linear acceleration of >70g and 6.2% had peak rotational acceleration >7900 rad/s². There were significant differences in the number and magnitude of impacts, quantified by the accelerometer, between three training sessions of differing intensity (ŋ2 0.03-0.09, p < 0.001). This study represents a first step in quantifying head impacts during hurling, demonstrating the feasibility of this technology in the field. The sensors were able to discriminate between sessions of varying intensity. These data can be used to develop athlete monitoring protocols and may be useful in developing innovative helmet-testing standards for hurling. The potential for this technology to provide feedback has clinical utility for team medical personnel.

Dynamic sentinel node biopsy for penile cancer: an initial experience in an Irish Hospital

BACKGROUND

The presence of nodal metastases is the single most important prognostic factor in penile cancer. However, reliable assessment of nodal status in clinically node-negative (cN0) patients poses a challenge. Approximately 20% of these patients harbour occult nodal metastases. Currently available non-invasive radiological investigations are unreliable in excluding micrometastatic disease.

AIM

Dynamic sentinel node biopsy (DSNB) is a minimally invasive procedure for assessing lymph node involvement. We report our initial experience with DSNB in assessing the status of regional lymph nodes in cN0 penile cancer patients.

METHODS

DSNB was performed in penile cancer patients with at least one cN0 groin. All patients undergoing DSNB at our institution were included. Lymphoscintigraphic images were obtained from all patients, after intradermal, peritumoral injection of a Technetium-99m nanocolloid. The sentinel nodes were defined as the nodes identified on lymphoscintigraphy, which were also radioactive intraoperatively using a gamma probe.

RESULTS

In total, 18 groins from 11 patients underwent DSNB. Of these, 11 patients underwent bilateral DSNB and 4 had unilateral DSNB. The mean (range) age of patients at the time of presentation of their primary tumour was 63 (39-78) years. A mean of 1.2 nodes per groin was retrieved. One lymph node was positive in one patient, who subsequently underwent a bilateral inguinal lymph node dissection. Overall, the median (range) follow-up was 12.8 (2.7-31.3) months with no local or regional recurrences.

CONCLUSION

Further cases and longer follow-up will define the accuracy of this technique in the Irish population.

Mobile Medical Apps and mHealth Devices: A Framework to Build Medical Apps and mHealth Devices in an Ethical Manner to Promote Safer Use - A Literature Review

This paper presents a preliminary literature review in the area of ethics in the development of Mobile Medical Apps and mHealth. The review included both direct health apps and also apps marketed under the area of well-being in addition to mHealth devices. The following words and combinations of them were used to carry out the search for publications, mHealth, Apps, Ethics. The search engines used were Google Scholar, and PubMed. The paper is restricted to publications since 2012. The total number of papers found was 1,920 of which 84 were reviewed. The reason for so few being reviewed was that the majority only considered security. The search revealed many papers dealing with security for all types of apps and mHealth devices but there are very few papers dealing with the ethical issues related to Apps or mHealth devices in the area. It is noted however that the number of apps is increasing in number exponentially and therefore it is argued that it is necessary to pay attention to the ethical aspects. There are now estimated to be 165,000 apps available in this area. How ethics are addressed in health and well-being apps is important as they can have an effect on the health of the individual using them. In a similar way, the need for addressing ethical issues for development of well-being apps is evident. In a study [1] it was noted that even though Electronic Health Record (EHR) was the highest ranked tablet-related task only one third of clinicians said that EHR was optimized for smartphones. When apps are integrated with the EHR they fully optimize productivity. In the same study the significant challenges identified included the method of evaluation and selection of mobile health solutions in order to ensure that clinical outcomes, care and efficiency are included. Security is mentioned but again wider ethical issues were not a consideration. From the literature review it is clear that there is a need for guidelines for how developers of medical ad well-being apps and mHealth devices should address ethical issues during development, and the generation of these guidelines is the subject of ongoing research by the authors.

Anticholinergic burden in schizophrenia and ability to benefit from psychosocial treatment programmes: a 3-year prospective cohort study

BACKGROUND

Many medications administered to patients with schizophrenia possess anticholinergic properties. When aggregated, pharmacological treatments may result in a considerable anticholinergic burden. The extent to which anticholinergic burden has a deleterious effect on cognition and impairs ability to participate in and benefit from psychosocial treatments is unknown.

METHOD

Seventy patients were followed for approximately 3 years. The MATRICS consensus cognitive battery (MCCB) was administered at baseline. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. Ability to benefit from psychosocial programmes was measured using the DUNDRUM-3 Programme Completion Scale (D-3) at baseline and follow-up. Psychiatric symptoms were measured using the PANSS. Total antipsychotic dose was measured using chlorpromazine equivalents. Functioning was measured using the Social and Occupational Functioning Assessment Scale (SOFAS).

RESULTS

Mediation analysis found that the influence of anticholinergic burden on ability to participate and benefit from psychosocial programmes was completely mediated by the MCCB. For every 1-unit increase on the ACB scale, change scores for DUNDRUM-3 decreased by -0.27 points. This relationship appears specific to anticholinergic burden and not total antipsychotic dose. Moreover, mediation appears to be specific to cognition and not psychopathology. Baseline functioning also acted as mediator but only when MCCB was not controlled for.

CONCLUSIONS

Anticholinergic burden has a significant impact on patients' ability to participate in and benefit from psychosocial treatment programmes. Physicians need to be mindful of the cumulative effect that medications can have on patient cognition, functional capacity and ability to benefit from psychosocial treatments.

Late effects of chemotherapeutic agents on renal function in childhood cancer survivors: a review of the literature

BACKGROUND

Survival outcomes for childhood cancers have significantly improved. As more children are now surviving into adulthood, knowledge of the long-term effects of childhood cancer treatments has become the focus of research.

AIM

To determine what is known about the incidence of renal function impairment in childhood cancer survivors and to determine what is known about risk factors for developing renal function impairment following childhood cancer treatment.

METHODS

A comprehensive literature search was preformed to identify studies that investigated renal dysfunction in patients who were diagnosed with childhood cancer and treated with potentially nephrotoxic chemotherapeutic agents. Potentially nephrotoxic chemotherapeutic agents identified in the selection criteria include ifosfamide, cisplatin, carboplatin and methotrexate.

RESULTS

15 papers met the inclusion criteria. Renal function impairment was reported in 15 of 15 studies included in this literature review. The incidence of ifosfamide induced nephrotoxicity varied from 1 to 50 %. This variation may be due to the heterogeneity of reported outcome measurements. Treatment with cisplatin and carboplatin was associated with hypomagnesemia. The prevalence of hypomagnesemia varied from 7 to 29 %. This variation may be due to diversity of treatment protocols. The incidence of renal dysfunction following treatment with methotrexate was reported as 1.8 % and completely reversible.

CONCLUSION

As more childhood cancer survivors are reaching adulthood, a new niche of cancer research has emerged. Researchers are now investigating the late effects due to cytotoxic treatments. Renal function impairment is a potential late effect of treatment with nephrotoxic chemotherapeutic agents including ifosfamide, cisplatin, carboplatin and methotrexate.

Bayes-ReCCE

Linked Open Data consists of a large set of structured data knowledge bases which have been linked together, typically using equivalence statements. These equivalences usually take the form of owl:sameAs statements linking individuals, but links between classes are far less common. Often, the lack of linking between classes is because the relationships cannot be described as elementary one to one equivalences. Instead, complex correspondences referencing multiple entities in logical combinations are often necessary if we want to describe how the classes in one ontology are related to classes in a second ontology. In this paper the authors introduce a novel Bayesian Restriction Class Correspondence Estimation (Bayes-ReCCE) algorithm, an extensional approach to detecting complex correspondences between classes. Bayes-ReCCE operates by analysing features of matched individuals in the knowledge bases, and uses Bayesian inference to search for complex correspondences between the classes these individuals belong to. Bayes-ReCCE is designed to be capable of providing meaningful results even when only small amounts of matched instances are available. They demonstrate this capability empirically, showing that the complex correspondences generated by Bayes-ReCCE have a median F1 score of over 0.75 when compared against a gold standard set of complex correspondences between Linked Open Data knowledge bases covering the geographical and cinema domains. In addition, the authors discuss how metadata produced by Bayes-ReCCE can be included in the correspondences to encourage reuse by allowing users to make more informed decisions on the meaning of the relationship described in the correspondences.

The relevance of nanoscale biological fragments for ice nucleation in clouds

Most studies of the role of biological entities as atmospheric ice-nucleating particles have focused on relatively rare supermicron particles such as bacterial cells, fungal spores and pollen grains. However, it is not clear that there are sufficient numbers of these particles in the atmosphere to strongly influence clouds. Here we show that the ice-nucleating activity of a fungus from the ubiquitous genus Fusarium is related to the presence of nanometre-scale particles which are far more numerous, and therefore potentially far more important for cloud glaciation than whole intact spores or hyphae. In addition, we quantify the ice-nucleating activity of nano-ice nucleating particles (nano-INPs) washed off pollen and also show that nano-INPs are present in a soil sample. Based on these results, we suggest that there is a reservoir of biological nano-INPs present in the environment which may, for example, become aerosolised in association with fertile soil dust particles.

Improving Curated Web-Data Quality with Structured Harvesting and Assessment

This paper describes a semi-automated process, framework and tools for harvesting, assessing, improving and maintaining high-quality linked-data. The framework, known as DaCura1, provides dataset curators, who may not be knowledge engineers, with tools to collect and curate evolving linked data datasets that maintain quality over time. The framework encompasses a novel process, workflow and architecture. A working implementation has been produced and applied firstly to the publication of an existing social-sciences dataset, then to the harvesting and curation of a related dataset from an unstructured data-source. The framework's performance is evaluated using data quality measures that have been developed to measure existing published datasets. An analysis of the framework against these dimensions demonstrates that it addresses a broad range of real-world data quality concerns. Experimental results quantify the impact of the DaCura process and tools on data quality through an assessment framework and methodology which combines automated and human data quality controls.

British Dietetic Association evidence-based guidelines for the dietary management of Crohn's disease in adults

BACKGROUND

Crohn's disease is a debilitating chronic inflammatory bowel disease. Appropriate use of diet and nutritional therapy is integral to the overall management strategy of Crohn's disease. The aim was to develop evidence-based guidelines on the dietary management of Crohn's disease in adults.

METHODS

Questions relating to the dietary management of Crohn's disease were developed. These included the roles of enteral nutrition to induce remission, food re-introduction diets to structure food re-introduction and maintain remission, and dietary management of stricturing disease, as well as whether probiotics or prebiotics induce or maintain remission. A comprehensive literature search was conducted and relevant studies from January 1985 to November 2009 were identified using the electronic database search engines CINAHL, Cochrane Library, EMBASE, MEDLINE, Scopus and Web of Science. Evidence statements, recommendations, practical considerations and research recommendations were developed.

RESULTS

Fifteen research papers were critically appraised and the evidence formed the basis of these guidelines. Although corticosteroids appear to be more effective, enteral nutrition (elemental or non-elemental) can be offered as an alternative option to induce disease remission. After a course of enteral nutrition, food re-introduction diets may be useful to structure food re-introduction and help maintain disease remission. Dietary fibre is contraindicated in the presence of strictures as a result of the risk of mechanical obstruction. The use of probiotics and prebiotics is not currently supported.

CONCLUSIONS

As an alternative to corticosteroids, evidence supports enteral nutrition to induce disease remission. Food re-introduction diets provide structure to food re-introduction and help maintain disease remission. These guidelines aim to reduce variation in clinical practice.

Biomechanics of head injury in olympic taekwondo and boxing

Objective

The purpose was to examine differences between taekwondo kicks and boxing punches in resultant linear head acceleration (RLA), head injury criterion (HIC15), peak head velocity, and peak foot and fist velocities. Data from two existing publications on boxing punches and taekwondo kicks were compared.

Methods

For taekwondo head impacts a Hybrid II Crash Dummy (Hybrid II) head was instrumented with a tri-axial accelerometer mounted inside the Hybrid II head. The Hybrid II was fixed to a height-adjustable frame and fitted with a protective taekwondo helmet. For boxing testing, a Hybrid III Crash Dummy head was instrumented with an array of tri-axial accelerometers mounted at the head centre of gravity.

Results

Differences in RLA between the roundhouse kick (130.11±51.67 g) and hook punch (71.23±32.19 g, d = 1.39) and in HIC15 (clench axe kick: 162.63±104.10; uppercut: 24.10±12.54, d = 2.29) were observed.

Conclusions

Taekwondo kicks demonstrated significantly larger magnitudes than boxing punches for both RLA and HIC.

Comparing predictions made by a prediction model, clinical score, and physicians: pediatric asthma exacerbations in the emergency department

BACKGROUND

Asthma exacerbations are one of the most common medical reasons for children to be brought to the hospital emergency department (ED). Various prediction models have been proposed to support diagnosis of exacerbations and evaluation of their severity.

OBJECTIVES

First, to evaluate prediction models constructed from data using machine learning techniques and to select the best performing model. Second, to compare predictions from the selected model with predictions from the Pediatric Respiratory Assessment Measure (PRAM) score, and predictions made by ED physicians.

DESIGN

A two-phase study conducted in the ED of an academic pediatric hospital. In phase 1 data collected prospectively using paper forms was used to construct and evaluate five prediction models, and the best performing model was selected. In phase 2 data collected prospectively using a mobile system was used to compare the predictions of the selected prediction model with those from PRAM and ED physicians.

MEASUREMENTS

Area under the receiver operating characteristic curve and accuracy in phase 1; accuracy, sensitivity, specificity, positive and negative predictive values in phase 2.

RESULTS

In phase 1 prediction models were derived from a data set of 240 patients and evaluated using 10-fold cross validation. A naive Bayes (NB) model demonstrated the best performance and it was selected for phase 2. Evaluation in phase 2 was conducted on data from 82 patients. Predictions made by the NB model were less accurate than the PRAM score and physicians (accuracy of 70.7%, 73.2% and 78.0% respectively), however, according to McNemar's test it is not possible to conclude that the differences between predictions are statistically significant.

CONCLUSION

Both the PRAM score and the NB model were less accurate than physicians. The NB model can handle incomplete patient data and as such may complement the PRAM score. However, it requires further research to improve its accuracy.

Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact

WHAT IS KNOWN AND OBJECTIVE

Potentially inappropriate prescribing (PIP) has significant clinical, humanistic and economic impacts. Identifying PIP in older adults may reduce their burden of adverse drug events. Tools with explicit criteria are being developed to screen for PIP in this population. These tools vary in their ability to identify PIP in specific care settings and jurisdictions due to such factors as local prescribing practices and formularies. One promising set of screening tools are the STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) and START (Screening Tool of Alert doctors to the Right Treatment) criteria. We conducted a systematic review of research studies that describe the application of the STOPP/START criteria and examined the evidence of the impact of STOPP/START on clinical, humanistic and economic outcomes in older adults.

METHODS

We performed a systematic review of studies from relevant biomedical databases and grey literature sources published from January 2007 to January 2012. We searched citation and reference lists and contacted content experts to identify additional studies. Two authors independently selected studies using a predefined protocol. We did not restrict selection to particular study designs; however, non-English studies were excluded during the selection process. Independent extraction of articles by two authors used predefined data fields. For randomized controlled trials and observational studies comparing STOPP/START to other explicit criteria, we assessed risk of bias using an adapted tool.

RESULTS AND DISCUSSION

We included 13 studies: a single randomized controlled trial and 12 observational studies. We performed a descriptive analysis as heterogeneity of study populations, interventions and study design precluded meta-analysis. All observational studies reported the prevalence of PIP; however, the application of the criteria was not consistent across all studies. Seven of the observational studies compared STOPP/START with other explicit criteria. The STOPP/START criteria were reported to be more sensitive than the more-frequently-cited Beers criteria in six studies, but less sensitive than a set of criteria developed in Australia. The STOPP criteria identified more medications associated with adverse drug events than the 2002 version of the Beers criteria. Patients with PIP, as identified by STOPP, had an 85% increased risk of adverse drug events in one study (OR = 1·85, 95% CI: 1·51-2·26; P < 0·001). There was limited evidence that the application of STOPP/START criteria optimized prescribing. Research involving the application of STOPP/START on the impact on the quality of life was not found. The direct costs of PIP were documented in three studies from Ireland, but more extensive analyses on the economic impact or studies from other jurisdictions were not found.

WHAT IS NEW AND CONCLUSION

The STOPP/START criteria have been used to review the medication profiles of community-dwelling, acute care and long-term care older patients in Europe, Asia and North America. Observational studies have reported the prevalence and predictors of PIP. The STOPP/START criteria appear to be more sensitive than the 2002 version of the Beers criteria. Limited evidence was found related to the clinical and economic impact of the STOPP/START criteria.

A task-based support architecture for developing point-of-care clinical decision support systems for the emergency department

OBJECTIVES

The purpose of this study was to create a task-based support architecture for developing clinical decision support systems (CDSSs) that assist physicians in making decisions at the point-of-care in the emergency department (ED). The backbone of the proposed architecture was established by a task-based emergency workflow model for a patient-physician encounter.

METHODS

The architecture was designed according to an agent-oriented paradigm. Specifically, we used the O-MaSE (Organization-based Multi-agent System Engineering) method that allows for iterative translation of functional requirements into architectural components (e.g., agents). The agent-oriented paradigm was extended with ontology-driven design to implement ontological models representing knowledge required by specific agents to operate.

RESULTS

The task-based architecture allows for the creation of a CDSS that is aligned with the task-based emergency workflow model. It facilitates decoupling of executable components (agents) from embedded domain knowledge (ontological models), thus supporting their interoperability, sharing, and reuse. The generic architecture was implemented as a pilot system, MET3-AE--a CDSS to help with the management of pediatric asthma exacerbation in the ED. The system was evaluated in a hospital ED.

CONCLUSIONS

The architecture allows for the creation of a CDSS that integrates support for all tasks from the task-based emergency workflow model, and interacts with hospital information systems. Proposed architecture also allows for reusing and sharing system components and knowledge across disease-specific CDSSs.

Evolution of a surgical technique for posteroventral pallidotomy using CT/MR fusion and intraoperative macrostimulation

This is a prospective review of 60 posteroventral pallidotomies performed in 48 patients. Twelve patients had bilateral pallidotomies; five of these were staged and seven were performed simultaneously at the one surgical procedure. The report focuses on evolution of a surgical technique originally using the computed tomographic (CT) scan for target acquisition, culminating in a technique of fusing the magnetic resonance (MR) and CT scans. The technique involves macrostimulation with threshold identification of the optic tract and internal capsule. Utilizing the current procedure reproducible accurate lesions were made in the ansa lenticularis and internal pallidum as confirmed on postoperative MR scans. Initial results would indicate a very good effect on motor functions such as rigidity and dyskinesia and moderate to good effect on tremor. Secondary effects were seen on hypokinetic features such as on/off fluctuations, postural stability, gait dysfunction and limb bradykinesia. There was no injury to the internal capsule or optic tract throughout the series. Gait and postural stability were adversely affected in two patients early on in the series before the utilization of the MR/CT fusion technique and before the introduction of the current lesioning technique. There was no other adverse morbidity for the procedure.

Ice nucleation by particles immersed in supercooled cloud droplets

The formation of ice particles in the Earth's atmosphere strongly affects the properties of clouds and their impact on climate. Despite the importance of ice formation in determining the properties of clouds, the Intergovernmental Panel on Climate Change (IPCC, 2007) was unable to assess the impact of atmospheric ice formation in their most recent report because our basic knowledge is insufficient. Part of the problem is the paucity of quantitative information on the ability of various atmospheric aerosol species to initiate ice formation. Here we review and assess the existing quantitative knowledge of ice nucleation by particles immersed within supercooled water droplets. We introduce aerosol species which have been identified in the past as potentially important ice nuclei and address their ice-nucleating ability when immersed in a supercooled droplet. We focus on mineral dusts, biological species (pollen, bacteria, fungal spores and plankton), carbonaceous combustion products and volcanic ash. In order to make a quantitative comparison we first introduce several ways of describing ice nucleation and then summarise the existing information according to the time-independent (singular) approximation. Using this approximation in combination with typical atmospheric loadings, we estimate the importance of ice nucleation by different aerosol types. According to these estimates we find that ice nucleation below about -15 °C is dominated by soot and mineral dusts. Above this temperature the only materials known to nucleate ice are biological, with quantitative data for other materials absent from the literature. We conclude with a summary of the challenges our community faces.

Distinguishing objective from subjective assessments of the severity of medication-related safety events among people with Parkinson's disease: a qualitative study

WHAT IS KNOWN AND OBJECTIVE

Safety events indicating medication-related errors in Parkinson's disease (PD) are common but seldom studied, particularly from lay perspectives. Our objective was to study the meaning and significance to people living with PD of their experience of safety events.

METHODS

Twenty qualitative interviews were conducted by telephone with purposively sampled individuals with PD, a proxy, or both, throughout New Zealand. Themes identified from the data included joint assessments of the objective and subjective severity of the individual safety events.

RESULTS AND DISCUSSION

Most of the events indicated minor objective errors, whose severity was sometimes perceived as major, especially in the face of callous communication.

WHAT IS NEW AND CONCLUSION

Variation between objective and subjective assessments of the severity of possible errors indicated by safety events highlight the importance of distinguishing between, and using, both forms of assessment.

In situ randomised trial investigating abrasive effects of two desensitising toothpastes on dentine with acidic challenge prior to brushing

OBJECTIVES

To determine if brushing dentine with 2 moderate RDA desensitising toothpastes, results in a significant dentine wear difference and whether this difference continues to be relevant when preceded with an erosive challenge.

METHODS

An in situ, single centre, single blind, randomised, split mouth study, evaluated the difference in abrasion of 2 toothpastes (SFM - Sensodyne Fresh Mint(®) RDA 70; CPHM - Crest Pro-Health Clean Mint(®) RDA 120) in 28 healthy volunteers. Two toothpaste treatments were administered 3×/day, for each of the two 15 day periods, subjects wearing bi-lateral, lower buccal appliances each with 4 dentine sections. A 2 min extra-oral acidic challenge preceded toothbrushing for 2 study arms. Contact profilometry measured samples at baseline, days 5, 10 and 15.

RESULTS

Brushing with SFM was significantly less abrasive than brushing with CPHM at all time points, with or without a preceding acidic challenge (p<0.0001). The additional dentine loss arising from the erosive challenge prior to brushing with each paste was linear with time and independent of abrasive effect.

CONCLUSIONS

The desensiting toothpastes' RDA, directly related to dentine loss with toothbrushing. An acidic challenge prior to brushing did not negate the benefits of reduced wear from the lower RDA paste compared to the higher RDA paste. When brushing eroded dentine, the additional wear appeared independent of abrasive effect. Dentine hypersensitivity sufferers should be recommended to use a low-moderate RDA toothpaste, not to brush more than 2×/day and not immediately following an acidic challenge.

The Carmarthenshire Glaucoma Referral Refinement Scheme, a safe and efficient screening service

AIM

It has been previously shown that community refinement of glaucoma referrals is an efficient way to investigate and treat glaucoma suspects. The potential for false negatives has not been explored previously and we describe a scheme in which effort has been made to both assess and control for this, and report on its success.

METHODS

Trained optometrists were recruited to examine and investigate the patients referred with suspected glaucoma, with a view to decreasing false-positive rates in accordance with an agreed protocol. The randomly selected notes of 100 patients referred onward to the Hospital Eye Service (HES) by trained, accredited optometrists, and the notes and optic disc images of 100 randomly selected patients retained in the community were examined in order to determine the efficiency and safety of the scheme.

RESULTS

The scheme resulted in a 53% reduction in the total number of referrals to HES with a cost saving of £117 per patient. Analysis of patients referred resulted in a diagnosis of glaucoma or retention of patients in HES with suspected glaucoma in 83% and a good correlation between the hospital and optometric measurements. Analysis of notes and optic nerve images of patients not referred indicated no compromise on patient safety.

CONCLUSION

This study suggests that suspected glaucoma can be successfully refined in the community with benefits to both the patient and the hospital. We also suggest that such a scheme may be safe as well as cost-effective, a conclusion that has not as yet been reached by any other study.

Myoclonus-dystonia: significance of large SGCE deletions

Myoclonus-dystonia (M-D) is an autosomal-dominant movement disorder caused by mutations in SGCE. We investigated the frequency and type of SGCE mutations with emphasis on gene dosage alterations and explored the associated phenotypes. We tested 35 M-D index patients by multiplex ligation-dependent probe amplification (MLPA) and genomic sequencing. Mutations were found in 26% (9/35) of the cases, all but three with definite M-D. Two heterozygous deletions of the entire SGCE gene and flanking DNA and a heterozygous deletion of exon 2 only were detected, accounting for 33% (3/9) of the mutations found. Both large deletions contained COL1A2 and were additionally associated with joint problems. Further, we discovered one novel small deletion (c.771_772delAT, p.C258X) and four recurrent point mutations (c.289C>T, p.R97X; c.304C>T, p.R102X; c.709C>T, p.R237X; c.1114C>T, p.R372X). A Medline search identified 22 articles on SGCE mutational screening. Sixty-four unrelated M-D patients were described with 41 different mutations. No genotype-phenotype association was found, except in patients with deletions encompassing additional genes. In conclusion, a rigorous clinical preselection of patients and careful accounting for non-motor signs should precede mutational tests. Gene dosage studies should be included in routine SGCE genetic testing.

Exposure to galactic cosmic radiation and solar energetic particles

Several investigations of the radiation field at aircraft altitudes have been undertaken during solar cycle 23 which occurred in the period 1993-2003. The radiation field is produced by the passage of galactic cosmic rays and their nuclear reaction products as well as solar energetic particles through the Earth's atmosphere. Galactic cosmic rays reach a maximum intensity when the sun is least active and are at minimum intensity during solar maximum period. During solar maximum an increased number of coronal mass ejections and solar flares produce high energy solar particles which can also penetrate down to aircraft altitudes. It is found that the very complicated field resulting from these processes varies with altitude, latitude and stage of solar cycle. By employing several active and passive detectors, the whole range of radiation types and energies were encompassed. In-flight data was obtained with the co-operation of many airlines and NASA. The EURADOS Aircraft Crew in-flight data base was used for comparison with the predictions of various computer codes. A brief outline of some recent studies of exposure to radiation in Earth orbit will conclude this contribution.