Measuring Quality of Healthcare Outcomes in Type 2 Diabetes from Routine Data: a Seven-nation Survey Conducted by the IMIA Primary Health Care Working Group.

Background: The Institute of Medicine framework defines six dimensions of quality for healthcare systems: (1) safety, (2) effectiveness, (3) patient centeredness, (4) timeliness of care, (5) efficiency, and (6) equity. Large health datasets provide an opportunity to assess quality in these areas. Objective: To perform an international comparison of the measurability of the delivery of these aims, in people with type 2 diabetes mellitus (T2DM) from large datasets. Method: We conducted a survey to assess healthcare outcomes data quality of existing databases and disseminated this through professional networks. We examined the data sources used to collect the data, frequency of data uploads, and data types used for identifying people with T2DM. We compared data completeness across the six areas of healthcare quality, using selected measures pertinent to T2DM management. Results: We received 14 responses from seven countries (Australia, Canada, Italy, the Netherlands, Norway, Portugal, Turkey and the UK). Most databases reported frequent data uploads and would be capable of near real time analysis of healthcare quality.The majority of recorded data related to safety (particularly medication adverse events) and treatment efficacy (glycaemic control and microvascular disease). Data potentially measuring equity was less well recorded. Recording levels were lowest for patient-centred care, timeliness of care, and system efficiency, with the majority of databases containing no data in these areas. Databases using primary care sources had higher data quality across all areas measured. Conclusion: Data quality could be improved particularly in the areas of patient-centred care, timeliness, and efficiency. Primary care derived datasets may be most suited to healthcare quality assessment.

Glucose test provenance recording in UK primary care: was that fasted or random?

AIMS: To describe the proportion of glucose tests with unrecorded provenance in routine primary care data and identify the impact on clinical practice. METHODS: A cross-sectional analysis was conducted of blood glucose measurements from the Royal College of General Practitioner Research and Surveillance Centre database, which includes primary care records from >100 practices across England and Wales. All blood glucose results recorded during 2013 were identified. Tests were grouped by provenance (fasting, oral glucose tolerance test, random, none specified and other). A clinical audit in a single primary care practice was also performed to identify the impact of failing to record glucose provenance on diabetes diagnosis. RESULTS: A total of 2 137 098 people were included in the cross-sectional analysis. Of 203 350 recorded glucose measurements the majority (117 893; 58%) did not have any provenance information. The most commonly reported provenance was fasting glucose (75 044; 37%). The distribution of glucose values where provenance was not recorded was most similar to that of fasting samples. The glucose measurements of 256 people with diabetes in the audit practice (size 11 514 people) were analysed. The initial glucose measurement had no provenance information in 164 cases (64.1%). A clinician questioned the provenance of a result in 41 cases (16.0%); of these, 14 (34.1%) required repeating. Lack of provenance led to delays in the diagnosis of diabetes [median (range) 30 (3-614) days]. CONCLUSIONS: The recording of glucose provenance in UK primary care could be improved. Failure to record provenance causes unnecessary repeated testing, delayed diagnosis and wasted clinician time.

Association between glycaemic control and common infections in people with Type 2 diabetes: a cohort study.

AIM: To investigate the impact of glycaemic control on infection incidence in people with Type 2 diabetes. METHODS: We compared infection rates during 2014 in people with Type 2 diabetes and people without diabetes in a large primary care cohort in the UK (the Royal College of General Practitioners Research and Surveillance Centre database). We performed multilevel logistic regression to investigate the impact of Type 2 diabetes on presentation with infection, and the effect of glycaemic control on presentation with upper respiratory tract infections, bronchitis, influenza-like illness, pneumonia, intestinal infectious diseases, herpes simplex, skin and soft tissue infections, urinary tract infections, and genital and perineal infections. People with Type 2 diabetes were stratified by good [HbA1c < 53 mmol/mol (< 7%)], moderate [HbA1c 53-69 mmol/mol (7-8.5%)] and poor [HbA1c > 69 mmol/mol (> 8.5%)] glycaemic control using their most recent HbA1c concentration. Infection incidence was adjusted for important sociodemographic factors and patient comorbidities. RESULTS: We identified 34 278 people with Type 2 diabetes and 613 052 people without diabetes for comparison. The incidence of infections was higher in people with Type 2 diabetes for all infections except herpes simplex. Worsening glycaemic control was associated with increased incidence of bronchitis, pneumonia, skin and soft tissue infections, urinary tract infections, and genital and perineal infections, but not with upper respiratory tract infections, influenza-like illness, intestinal infectious diseases or herpes simplex. CONCLUSIONS: Almost all infections analysed were more common in people with Type 2 diabetes. Infections that are most commonly of bacterial, fungal or yeast origin were more frequent in people with worse glycaemic control.

The effect of a structured programme to increase patient activity during inpatient stroke rehabilitation: a Phase I cohort study.

OBJECTIVE: To develop an intervention and undertake a proof-of-concept evaluation of its feasibility, acceptability, and impact on recorded patient activity levels during inpatient stroke rehabilitation. DESIGN: A longitudinal cohort design. SETTING: Three inpatient stroke rehabilitation services. SUBJECTS: Stroke survivors receiving inpatient rehabilitation. INTERVENTION: A programme designed to increase patient activity, including individualised patient timetables, independent practice, therapeutic group work, and structured social activities was developed and implemented without additional resource. MAIN MEASURES: Patients' recorded activity levels were compared for two weeks before and after implementation of the programme. Data regarding the estimated time spent in different types of activity were extracted from patient treatment records, patients' and therapists' diaries, or timetables (if used) to measure patient activity levels RESULTS: At baseline, recorded activity levels were low; patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation of the programme, recorded activity levels significantly increased to a mean of 123 minutes (SD = 88) per day (p = 0.0001). The time spent in all types of recorded activity increased (p = 0.0001-0.002), except psychology where the increase did not reach significance (p = 0.670). CONCLUSIONS: A structured programme can significantly increase recorded patient activity levels during inpatient stroke rehabilitation without additional resource.

Cognitive control, reward-related decision making and outcomes of late-life depression treated with an antidepressant.

BACKGROUND: Executive processes consist of at least two sets of functions: one concerned with cognitive control and the other with reward-related decision making. Abnormal performance in both sets occurs in late-life depression. This study tested the hypothesis that only abnormal performance in cognitive control tasks predicts poor outcomes of late-life depression treated with escitalopram. METHOD: We studied older subjects with major depression (N = 53) and non-depressed subjects (N = 30). Executive functions were tested with the Iowa Gambling Test (IGT), Stroop Color-Word Test, Tower of London (ToL), and Dementia Rating Scale - Initiation/Perseveration domain (DRS-IP). After a 2-week placebo washout, depressed subjects received escitalopram (target daily dose: 20 mg) for 12 weeks. RESULTS: There were no significant differences between depressed and non-depressed subjects on executive function tests. Hierarchical cluster analysis of depressed subjects identified a Cognitive Control cluster (abnormal Stroop, ToL, DRS-IP), a Reward-Related cluster (IGT), and an Executively Unimpaired cluster. Decline in depression was greater in the Executively Unimpaired (t = -2.09, df = 331, p = 0.0375) and the Reward-Related (t = -2.33, df = 331, p = 0.0202) clusters than the Cognitive Control cluster. The Executively Unimpaired cluster (t = 2.17, df = 331, p = 0.03) and the Reward-Related cluster (t = 2.03, df = 331, p = 0.0433) had a higher probability of remission than the Cognitive Control cluster. CONCLUSIONS: Dysfunction of cognitive control functions, but not reward-related decision making, may influence the decline of symptoms and the probability of remission of late-life depression treated with escitalopram. If replicated, simple to administer cognitive control tests may be used to select depressed older patients at risk for poor outcomes to selective serotonin reuptake inhibitors who may require structured psychotherapy.

The impact of a toolkit on use of standardised measurement tools in stroke rehabilitation.

OBJECTIVE: To evaluate the impact of a toolkit of psychometrically robust measurement tools, the Greater Manchester Assessment for Stroke Rehabilitation (G-MASTER) toolkit, on the use of measurement tools during stroke rehabilitation DESIGN: Mixed methods cohort design using non-participant observation of multi-disciplinary team meetings and semi-structured interviews with members of the team over three months before and three months after implementation of the assessment toolkit. Development and implementation of the toolkit are also described. SETTING: Ten in-patient stroke services in a large UK city. SUBJECTS: Members of the participating multi-disciplinary stroke teams. RESULTS: Before implementation standardised measures were seldom used in team meetings. After implementation, use of all measurement tools significantly increased (36% to 81% of occasions, P<0.000). Staff were generally positive about the toolkit and felt it enabled more accurate problem identification, effective progress monitoring, timely decision-making, communication and promoted inter-team relationships. CONCLUSIONS: A toolkit of standardised measurement tools can be feasibly and acceptably implemented into stroke rehabilitation. It increases the use of measurement tools by the multi-disciplinary team and improves the processes and quality of care.

Multi-disciplinary team meetings in stroke rehabilitation: an observation study and conceptual framework.

OBJECTIVE: To explore how multi-disciplinary team meetings operate in stroke rehabilitation. DESIGN: Non-participant observation of multi-disciplinary team meetings and semi-structured interviews with attending staff. SETTING AND PARTICIPANTS: Twelve meetings were observed (at least one at each site) and 18 staff (one psychologist, one social worker; four nurses; four physiotherapists four occupational therapists, two speech and language therapists, one stroke co-ordinator and one stroke ward manager) were interviewed in eight in-patient stroke rehabilitation units. RESULTS: Multi-disciplinary team meetings in stroke rehabilitation were complex, demanding and highly varied. A model emerged which identified the main inputs to influence conduct of the meetings were personal contributions of the members and structure and format of the meetings. These were mediated by the team climate and leadership skills of the chair. The desired outputs; clinical decisions and the attributes of apparently effective meetings were identified by the staff. A notable difference between the meetings that staff considered effective and those that were not, was their structure and format. Successful meetings tended to feature a set agenda, structured documentation; formal use of measurement tools; pre-meeting preparation and skilled chairing. These features were often absent in meetings perceived to be ineffective. CONCLUSIONS: The main features of operation of multi-disciplinary team meetings have been identified which will enable assessment tools and interventions to improve effectiveness to be developed.

Metformin in obese children and adolescents: the MOCA trial.

CONTEXT: Childhood obesity is increasingly associated with type 2 diabetes (T2D). Metformin reduces the risk for T2D in adult obese nondiabetic patients, but the evidence in obese children and young people is inconclusive. OBJECTIVE: The objective of the study was to assess the effect of metformin on body mass index sd score (BMI-SDS), metabolic risk factors, and adipokines. DESIGN: This was a prospective, randomized, double-blind, placebo-controlled trial. SETTING: The study was conducted at six pediatric endocrine centers in the United Kingdom. PARTICIPANTS: One hundred fifty-one obese children and young people with hyperinsulinemia and/or impaired fasting glucose or impaired glucose tolerance (metformin: 74, placebo: 77). The study was comprised of 67.5% females, 65.6% postpubertal individuals, and 23.8% British Asian or Afro-Caribbean participants. The age range was 8-18 yr, the mean age was 13.7 (SD 2.3) yr, and the mean BMI-SDS was +3.4 (SD 0.5). INTERVENTIONS: The intervention included metformin 1 g in the morning and 500 mg in the evening vs. placebo for 6 months. MAIN OUTCOME MEASURE: The main outcome measure was a reduction in BMI-SDS at 6 months. Secondary outcomes included insulin and glucose levels from oral glucose tolerance tests, alanine aminotransferase (ALT), and adiponectin to leptin ratio (ALR) at 3 and 6 months. RESULTS: Metformin was associated with a significant reduction in BMI-SDS compared with placebo at 6 months [mean difference -0.1 SD (95% confidence interval -0.18 to -0.02), P = 0.02]. Significant improvements at 3 months were found in the metformin group: fasting glucose, -0.16 mmol/liter (-0.31 to -0.00), P = 0.047; ALT, 19% (5-36%), P = 0.008; and ALR, 32% (4-67%), P = 0.02. CONCLUSIONS: Metformin therapy has a beneficial treatment effect over placebo for BMI-SDS, fasting glucose, ALT, and ALR ratio at 3 months, with changes in BMI-SDS sustained at 6 months.

Transneuronal tracing of airways-related sensory circuitry using herpes simplex virus 1, strain H129.

Sensory input from the airways to suprapontine brain regions contributes to respiratory sensations and the regulation of respiratory function. However, relatively little is known about the central organization of this higher brain circuitry. We exploited the properties of the H129 strain of herpes simplex virus 1 (HSV-1) to perform anterograde transneuronal tracing of the central projections of airway afferent nerve pathways. The extrathoracic trachea in Sprague-Dawley rats was inoculated with HSV-1 H129, and tissues along the neuraxis were processed for HSV-1 immunoreactivity. H129 infection appeared in the vagal sensory ganglia within 24 h and the number of infected cells peaked at 72 h. Brainstem nuclei, including the nucleus of the solitary tract and trigeminal sensory nuclei were infected within 48 h, and within 96 h infected cells were evident within the pons (lateral and medial parabrachial nuclei), thalamus (ventral posteromedial, ventral posterolateral, submedius, and reticular nuclei), hypothalamus (paraventricular and lateral nuclei), subthalamus (zona incerta), and amygdala (central and anterior amygdala area). At later times H129 was detected in cortical forebrain regions including the insular, orbital, cingulate, and somatosensory cortices. Vagotomy significantly reduced the number of infected cells within vagal sensory nuclei in the brainstem, confirming the main pathway of viral transport is through the vagus nerves. Sympathetic postganglionic neurons in the stellate and superior cervical ganglia were infected by 72 h, however, there was no evidence for retrograde transynaptic movement of the virus in sympathetic pathways in the central nervous system (CNS). These data demonstrate the organization of key structures within the CNS that receive afferent projections from the extrathoracic airways that likely play a role in the perception of airway sensations.

Effects of storage and the presence of a beef microflora on the thermal resistance of Salmonella Typhimurium DT104 in beef and broth systems.

AIMS: To investigate the effects of storage and the presence of a beef microflora on the thermal resistance of Salmonella serotype Typhimurium DT104 on beef surfaces and in a broth system during subsequent heat treatments after extended low-temperature storage (4 degrees C for 14 days) or mild temperature abuse (10 degrees C for 7 days). METHODS AND RESULTS: Surviving Salm. Typhimurium DT104 cells were estimated after heating in a water bath (55 degrees C) by plating beef and broth samples on tryptone soya agar and overlaying with xylose-lysine-deoxycholate agar. In beef and broth systems, D(55) values for Salm. Typhimurium DT104 stored at 4 degrees C or 10 degrees C in the presence or absence of a beef microflora were significantly lower (P < 0.01) than the D values for this organism heat-treated immediately after inoculation. In beef systems, the D(55) values were significantly lower (P < 0.05) in the presence of a beef microflora than the D(55) values obtained in 'pure' culture under all temperature/storage combinations. However, in broth systems, there was no significant difference between the D(55) values obtained in 'pure' culture and the D(55) values obtained from systems containing beef microflora. CONCLUSIONS: Storage of Salm. Typhimurium DT104 significantly reduced the thermal resistance of the pathogen in beef and broth systems. In the presence of high numbers of a Gram-negative beef microflora, the heat sensitivity of the pathogen was further increased on beef surfaces but not in broth. SIGNIFICANCE AND IMPACT OF THE STUDY: Studies investigating the survival of Salm. Typhimurium DT104 in different food systems will help define safe food preservation processes and will aid in the elimination this pathogen from the food production environments.

Surface decontamination of beef inoculated with Salmonella Typhimurium DT104 or Escherichia coli O157:H7 using dry air in a novel heat treatment apparatus.

AIMS: To determine the effectiveness of a novel dry air decontamination apparatus in the deactivation of Salmonella serotype Typhimurium DT104 or Escherichia coli O157:H7 on beef surfaces. METHODS AND RESULTS: A laboratory scale dry air decontamination apparatus, capable of producing repeatable and known heating time-temperature cycles on food surfaces was used in decontamination trials. Beef samples were surface inoculated with 7-8 log10CFU cm(-2) of S. Typhimurium DT104 or E. coli O157:H7 and heated at 60, 75, 90 and 100 degrees C using fast and slow heating rates and subsequently held at these temperatures for up to 600 s. A substantial reduction in pathogen numbers was achieved at higher temperatures (90 and 100 degrees C, 4.18-6.06 log10CFU cm(-2)) using both heating rates, but cell survival at these temperatures was also observed. At the lower temperatures, deactivation was small at 60 degrees C in particular it was less than one log unit after 3 min heating. No significant differences were observed when total reductions in pathogen counts were compared for all the temperature/heat up time combinations tested. During slow heating at 90 degrees C, and both heating rates at 100 degrees C, the pattern of deactivation of S. Typhimurium DT104 or E. coli O157:H7 was triphasic. CONCLUSIONS: This study has shown that heating meat surfaces with dry air can achieve substantial reductions in S. Typhimurium DT104 or E. coli O157:H7. As surface decontamination of beef surfaces with dry air had a negative effect on beef colour and appearance, such a decontamination apparatus would be unsuitable for producing meat for retail sale but it could be used to produce safer meat for use in the catering trade. SIGNIFICANCE AND IMPACT OF THE STUDY: This study provides researchers and food processors with data on the dynamic changes in S. Typhimurium DT104 and E. coli O157:H7 counts on intact beef surfaces during heating with dry air under realistic (time-varying) temperature conditions.

Controlled trial of distal radial fractures treated with a resorbable bone mineral substitute.

This randomized trial compared the use of hydroxyapatite cement with Kapandji wiring in distal radial fractures. Two groups of nine patients with distal radial fractures were either treated by reduction and fixation with wires or insertion of the cement into the fracture void. There was no difference between the groups before operation, on reduction or at day 1. Dorsal angle in the hydroxyapatite group was significantly worse at 6, 12 and 26 weeks. Grip strength and palmar flexion were poor in the hydroxyapatite cement group. All the clinical parameters and X-ray variables were worse at 12 and 26 weeks in the hydroxyapatite cement group. We conclude from this trial that there is nothing to support the use of this hydroxyapatite cement, without the use of additional fixation, in distal radial fractures.

Detection of the dipicolinic acid biomarker in Bacillus spores using Curie-point pyrolysis mass spectrometry and Fourier transform infrared spectroscopy.

Thirty-six strains of aerobic endospore-forming bacteria confirmed by polyphasic taxonomic methods to belong to Bacillus amyloliquefaciens, Bacillus cereus, Bacillus licheniformis, Bacillus megaterium, Bacillus subtilis (including Bacillus niger and Bacillus globigii), Bacillus sphaericus, and Brevi laterosporus were grown axenically on nutrient agar, and vegetative and sporulated biomasses were analyzed by Curie-point pyrolysis mass spectrometry (PyMS) and diffuse reflectance-absorbance Fourier-transform infrared spectroscopy (FT-IR). Chemometric methods based on rule induction and genetic programming were used to determine the physiological state (vegetative cells or spores) correctly, and these methods produced mathematical rules which could be simply interpreted in biochemical terms. For PyMS it was found that m/z 105 was characteristic and is a pyridine ketonium ion (C6H3ON+) obtained from the pyrolysis of dipicolinic acid (pyridine-2,6-dicarboxylic acid; DPA), a substance found in spores but not in vegetative cells; this was confirmed using pyrolysis-gas chromatography/mass spectrometry. In addition, a pyridine ring vibration at 1447-1439 cm-1 from DPA was found to be highly characteristic of spores in FT-IR analysis. Thus, although the original data sets recorded hundreds of spectral variables from whole cells simultaneously, a simple biomarker can be used for the rapid and unequivocal detection of spores of these organisms.

Rapid analysis of high-dimensional bioprocesses using multivariate spectroscopies and advanced chemometrics.

There are an increasing number of instrumental methods for obtaining data from biochemical processes, many of which now provide information on many (indeed many hundreds) of variables simultaneously. The wealth of data that these methods provide, however, is useless without the means to extract the required information. As instruments advance, and the quantity of data produced increases, the fields of bioinformatics and chemometrics have consequently grown greatly in importance. The chemometric methods nowadays available are both powerful and dangerous, and there are many issues to be considered when using statistical analyses on data for which there are numerous measurements (which often exceed the number of samples). It is not difficult to carry out statistical analysis on multivariate data in such a way that the results appear much more impressive than they really are. The authors present some of the methods that we have developed and exploited in Aberystwyth for gathering highly multivariate data from bioprocesses, and some techniques of sound multivariate statistical analyses (and of related methods based on neural and evolutionary computing) which can ensure that the results will stand up to the most rigorous scrutiny.

Community members' perceptions of evidence: the effects of gender in a recovered memory civil trial.

Community members judged a civil trial in which a memory had either been recovered or kept secret until therapy 12 years later. Female jurors were more likely to find the defendant liable and to compensate female plaintiffs more than male plaintiffs, whereas the reverse pattern held for male jurors. Female plaintiffs who reported recovered memories were compensated least, whereas female plaintiffs who kept the abuse secret were compensated most. A mediational model was posited and results indicated that the origin of the memory of sexual abuse and victim gender influenced assessments of trial testimonies that were related to the trial outcomes. Results supported the postulated model and indicated significant juror-gender differences in evaluating and weighing the evidence.

Rapid analysis of the expression of heterologous proteins in Escherichia coli using pyrolysis mass spectrometry and Fourier transform infrared spectroscopy with chemometrics: application to alpha 2-interferon production.

Cell pastes and supernatant Escherichia coli samples, taken from an industrial bioprocess overproducing recombinant alpha 2 IFN were analysed using pyrolysis mass spectrometry (PyMS) and diffuse reflectance-absorbance Fourier transform infrared spectroscopy (FT-IR). PyMS and FT-IR are physico-chemical methods which measure predominantly the bond strengths of molecules and the vibrations of bonds within functional groups, respectively. They therefore give quantitative information about the total biochemical composition of the bioprocess sample. The interpretation of these hyperspectral data, in terms of the quantity of alpha 2 IFN in the cell pastes and supernatant samples was possible only after the application of the 'supervised learning' methods of artificial neural networks (ANNs) and partial least squares (PLS) regression. Both PyMS and FT-IR are novel, rapid and economical methods for the screening and the quantitative analysis of complex biological bioprocess over producing recombinant proteins. Models established using either spectral data set had a similarly satisfactory predictive ability. This shows that whole-reaction mixture spectral methods, which measure all molecules simultaneously, do contain enough information to allow their quantification when the entire spectra are used as the inputs to methods based on supervised learning. Moreover, this is the first study where FT-IR in the mid-IR range has been used to quantify the expression of a heterologous protein directly from fermentation broths and the first study to compare the abilities of PyMS and FT-IR for the quantitative analyses of an industrial bioprocess.

Children's understanding of the meaning and functions of verbal irony.

We investigated children's understanding of irony and sensitivity to irony's meanness and humor. In Study 1, 89 participants (5-6-year-olds, 8-9-year-olds, adults) heard ironic and literal criticisms, and literal compliments. Comprehension of irony emerged between 5 and 6 years of age. Ratings of humor increased with age; ratings of meanness did not (showing that all ages perceived irony as more muted than literal criticism). In Study 2, results from 135 participants (6-7-year-olds, 8-9-year-olds, and adults) replicated these findings and revealed the role of form and intonation. Thus, comprehension of irony emerges between 5 and 6 years of age, and sensitivity to the muting function develops prior to sensitivity to the humor function.

The state of the device and copper levels in the products of conception in women becoming pregnant with a copper-bearing IUD in situ.

Of the 8 pregnancies studied, 2 were of small gestational sacs with blighted ova and were associated with devices in which the copper wire had very high detectable X-ray emissions for copper (greater than 90%). In 2 other pregnancies intrauterine deaths had occurred by the time of termination at 13 and 17 weeks and copper levels in the products of conception were variable. There was no abnormality of the fetus in the term pregnancy but it seems possible that copper can affect the early growth and development of the embryo. On only 1 of the 8 devices was any great amount of calcium deposited and it is therefore considered unlikely that calcium deposition increases the risk of pregnancy by preventing the release of copper.