C-peptide and metabolic outcomes in trials of disease modifying therapy in new-onset type 1 diabetes: an individual participant meta-analysis

BACKGROUND

Metabolic outcomes in type 1 diabetes remain suboptimal. Disease modifying therapy to prevent β-cell loss presents an alternative treatment framework but the effect on metabolic outcomes is unclear. We, therefore, aimed to define the relationship between insulin C-peptide as a marker of β-cell function and metabolic outcomes in new-onset type 1 diabetes.

METHODS

21 trials of disease-modifying interventions within 100 days of type 1 diabetes diagnosis comprising 1315 adults (ie, those 18 years and older) and 1396 children (ie, those younger than 18 years) were combined. Endpoints assessed were stimulated area under the curve C-peptide, HbA1c, insulin use, hypoglycaemic events, and composite scores (such as insulin dose adjusted A1c, total daily insulin, U/kg per day, and BETA-2 score). Positive studies were defined as those meeting their primary endpoint. Differences in outcomes between active and control groups were assessed using the Wilcoxon rank test.

FINDINGS

6 months after treatment, a 24·8% greater C-peptide preservation in positive studies was associated with a 0·55% lower HbA1c (p<0·0001), with differences being detectable as early as 3 months. Cross-sectional analysis, combining positive and negative studies, was consistent with this proportionality: a 55% improvement in C-peptide preservation was associated with 0·64% lower HbA1c (p<0·0001). Higher initial C-peptide levels and greater preservation were associated with greater improvement in HbA1c. For HbA1c, IDAAC, and BETA-2 score, sample size predictions indicated that 2-3 times as many participants per group would be required to show a difference at 6 months as compared with C-peptide. Detecting a reduction in hypoglycaemia was affected by reporting methods.

INTERPRETATION

Interventions that preserve β-cell function are effective at improving metabolic outcomes in new-onset type 1 diabetes, confirming their potential as adjuncts to insulin. We have shown that improvements in HbA1c are directly proportional to the degree of C-peptide preservation, quantifying this relationship, and supporting the use of C-peptides as a surrogate endpoint in clinical trials.

FUNDING

JDRF and Diabetes UK.

Multi-synaptic boutons are a feature of CA1 hippocampal connections in the stratum oriens

Excitatory synapses are typically described as single synaptic boutons (SSBs), where one presynaptic bouton contacts a single postsynaptic spine. Using serial section block-face scanning electron microscopy, we found that this textbook definition of the synapse does not fully apply to the CA1 region of the hippocampus. Roughly half of all excitatory synapses in the stratum oriens involved multi-synaptic boutons (MSBs), where a single presynaptic bouton containing multiple active zones contacted many postsynaptic spines (from 2 to 7) on the basal dendrites of different cells. The fraction of MSBs increased during development (from postnatal day 22 [P22] to P100) and decreased with distance from the soma. Curiously, synaptic properties such as active zone (AZ) or postsynaptic density (PSD) size exhibited less within-MSB variation when compared with neighboring SSBs, features that were confirmed by super-resolution light microscopy. Computer simulations suggest that these properties favor synchronous activity in CA1 networks.

Randomized phase I trial of antigen-specific tolerizing immunotherapy with peptide/calcitriol liposomes in ACPA+ rheumatoid arthritis

BACKGROUNDAntigen-specific regulation of autoimmune disease is a major goal. In seropositive rheumatoid arthritis (RA), T cell help to autoreactive B cells matures the citrullinated (Cit) antigen-specific immune response, generating RA-specific V domain glycosylated anti-Cit protein antibodies (ACPA VDG) before arthritis onset. Low or escalating antigen administration under "sub-immunogenic" conditions favors tolerance. We explored safety, pharmacokinetics, and immunological and clinical effects of s.c. DEN-181, comprising liposomes encapsulating self-peptide collagen II259-273 (CII) and NF-κB inhibitor 1,25-dihydroxycholecalciferol.METHODSA double-blind, placebo-controlled, exploratory, single-ascending-dose, phase I trial assessed the impact of low, medium, and high DEN-181 doses on peripheral blood CII-specific and bystander Cit64vimentin59-71-specific (Cit-Vim-specific) autoreactive T cell responses, cytokines, and ACPA in 17 HLA-DRB1*04:01+ or *01:01+ ACPA+ RA patients on methotrexate.RESULTSDEN-181 was well tolerated. Relative to placebo and normalized to baseline values, Cit-Vim-specific T cells decreased in patients administered medium and high doses of DEN-181. Relative to placebo, percentage of CII-specific programmed cell death 1+ T cells increased within 28 days of DEN-181. Exploratory analysis in DEN-181-treated patients suggested improved RA disease activity was associated with expansion of CII-specific and Cit-Vim-specific T cells; reduction in ACPA VDG, memory B cells, and inflammatory myeloid populations; and enrichment in CCR7+ and naive T cells. Single-cell sequencing identified T cell transcripts associated with tolerogenic TCR signaling and exhaustion after low or medium doses of DEN-181.CONCLUSIONThe safety and immunomodulatory activity of low/medium DEN-181 doses provide rationale to further assess antigen-specific immunomodulatory therapy in ACPA+ RA.TRIAL REGISTRATIONAnzctr.org.au identifier ACTRN12617001482358, updated September 8, 2022.FUNDINGInnovative Medicines Initiative 2 Joint Undertaking (grant agreement 777357), supported by European Union's Horizon 2020 research and innovation programme and European Federation of Pharmaceutical Industries and Associations; Arthritis Queensland; National Health and Medical Research Council (NHMRC) Senior Research Fellowship; and NHMRC grant 2008287.

The pericranial flap for inner lining of full-thickness nasal defects: a retrospective cohort study

BACKGROUND

Effective nasal reconstruction requires skin and soft tissue cover, cartilage or bone structure, and mucosal lining. Ideal lining is thin, pliable and vascularised, making reconstruction challenging. This paper presents the first case series with long-term outcomes of pericranial flaps used as inner lining for nasal reconstruction.

METHODS

Patients undergoing paramedial forehead flaps from 2007 to 2019 were identified using second-stage nasal reconstruction billing codes. Patients with pericranial flaps for lining, for whom there were data on resulting outcomes and complications, were identified.

RESULTS

Sixty-six patients underwent second-stage nasal reconstruction. Eighteen patients had paramedian forehead and pericranial flaps for inner lining reconstruction. The flap lining had no immediate post-operative complications. Three patients suffered partial to major reconstructive failure post radiotherapy. Other complications included nasal stenosis and orocutaneous fistula.

CONCLUSION

Combined with paramedian forehead flaps, the pericranial flap is reliable as inner lining for nasal reconstruction. It is easily accessible and useful in resections with limited mucosal options.

Voltage-Gated Potassium Channels Ensure Action Potential Shape Fidelity in Distal Axons

The initiation and propagation of the action potential (AP) along an axon allows neurons to convey information rapidly and across distant sites. Although AP properties have typically been characterized at the soma and proximal axon, knowledge of the propagation of APs toward distal axonal domains of mammalian CNS neurons remains limited. We used genetically encoded voltage indicators (GEVIs) to image APs with submillisecond temporal resolution simultaneously at different locations along the long axons of dissociated hippocampal neurons from rat embryos of either sex. We found that APs became sharper and showed remarkable fidelity as they traveled toward distal axons, even during a high-frequency train. Blocking voltage-gated potassium channels (Kv) with 4-AP resulted in an increase in AP width in all compartments, which was stronger at distal locations and exacerbated during AP trains. We conclude that the higher levels of Kv channel activity in distal axons serve to sustain AP fidelity, conveying a reliable digital signal to presynaptic boutons.SIGNIFICANCE STATEMENT The AP represents the electrical signal carried along axons toward distant presynaptic boutons where it culminates in the release of neurotransmitters. The nonlinearities involved in this process are such that small changes in AP shape can result in large changes in neurotransmitter release. Since axons are remarkably long structures, any distortions that APs suffer along the way have the potential to translate into a significant modulation of synaptic transmission, particularly in distal domains. To avoid these issues, distal axons have ensured that signals are kept remarkably constant and insensitive to modulation during a train, despite the long distances traveled. Here, we uncover the mechanisms that allow distal axonal domains to provide a reliable and faithful digital signal to presynaptic terminals.

P1598 Ruptured Sinus of Valsalva: clinical and echocardiographic features at presentation and long-term results after surgical and percutaneous repair

Background

Rupture of Sinus of Valsalva (rSOV) is a rare and potentially life-threatening condition often misdiagnosed. Percutaneous device closure has been replacing surgical repair as a treatment of choice. However, long-term outcome is poorly documented.

Methods

Echo database (2001-2019) was searched for patients &gt;16y with rSOV. Clinical data were collected from ACHD database. Marfan Syndrome patients were excluded.

Results

Fifteen patients (42.2y, 10M) were diagnosed with rSOVbetween 1979 and 2019. HF symptoms at initial presentation were reported in 50%. All cases were diagnosed by TTE with finding of high velocity continuous flow from SOV to right heart. Two were initially misdiagnosed as VSD. Digital imaging recordings of 10/15 were available. The aortic root was dilated in 8/10. Four had asymmetrical SOV dilatation. LV and LA were dilated in 7/10 and 9/10. Significant aortic regurgitation was in 4. Two had RVOTO. RVSP was always raised. Echo findings are summarised in the Table.

Mean FU after repair was 10,7y (0,9-39). Ten patients had surgical repair and 5 device closure. Seven had repair of concomitant lesions (4 VSD closure and 3 AVR) at the time of the procedure. One redo device closure was performed. During FU 1 died from Cardiomyopathy. At the latest FU significant improvement in functional class, LV and LA size and RVSP was found.

Conclusion

Patients with rSOV may present with acute HF. High velocity continuous flow from SOV to right heart on TTE is characteristic feature for diagnosis. Percutaneous closure is an attractive alternative to surgery in patients with isolated lesion. Significant haemodynamic improvement can be achieved with good long-term haemodynamic results

Tot = 15 Initial findings Latest FU NYHA class 4 class I 2 class II 2 class III 4 class IV 3 unknown 11 class I 2 class II 1 class III 0 class IV* SOV (mm) 38.2 (33-44) STJ (mm) 36.2 (26-42 Asc Ao (mm) 30.3 (25-34) rupture site 8 RC sinus, 2 NC sinus Shunt to 8 RVOT, 1 RA, 1 RVOT + RA LVEDV (ml) 169.7 (114-330) 120 (67-230)* LVESV (ml) 66(42-130) 46 (28-80)* LAVi (ml/m2) 53.1 (30-129) 35 (24-53)* LV EF% 61.2 (57-65) 60.4 (50-70) RVSP (mmHg) 53.2 (37-130) 24.06 (15-32)** Pre VS post procedure p-value: * P &lt; 0,05 **P &lt; 0,01

Abstract P1598 Figure. PLAX in patient with ruptured RC sinus

Organization and content of primary care for adolescents – comparison of actual and desired situation

To successfully navigate increasing autonomy, independence and health behaviors in adolescence, accessible adolescent health care services (AHS) are essential. AHS comprise all services in primary care that are aimed at the specific needs of adolescents and can be provided in various settings such as public services, private services, schools and hospitals. In the MOCHA project (Models of Child Health Appraised) we assessed the structure and content of AHS in 30 European countries against the standards in the field of adolescent health services: accessibility, staff attitude, communication, staff competency and skills, confidential and continuous care, age appropriate environment, involvement in health care, equity and respect and a strong link with the community. The results revealed that although half of the 30 countries did adopt adolescent-specific policies, many countries did not meet the current standards of quality health care for adolescents. For example, the ability to provide emergency mental health care is limited. In addition, one third of the countries do not have a formal policy which guarantees the confidentiality of a consult and the possibility to consult a physician without parents knowing. Finally, around half of the countries do not have specialized centers in adolescent health care in order to tackle comprehensive health issues. Access to adolescent health care services needs to be improved for vulnerable adolescents such as migrant adolescents. Schools, ambulatory settings and hospitals should offer accessible, comprehensive health care and a culturally appropriate approach, particularly given the number of migrant adolescents living in EU and EEA countries. Finally, the health care systems should improve their communication strategies, to assist young people in understanding their rights and responsibility in the domain of health, and how and where to access to adequate care.

In Vitro Modelling of Nerve-Muscle Connectivity in a Compartmentalised Tissue Culture Device

Motor neurons project axons from the hindbrain and spinal cord to muscle, where they induce myofibre contractions through neurotransmitter release at neuromuscular junctions. Studies of neuromuscular junction formation and homeostasis have been largely confined to in vivo models. In this study we have merged three powerful tools - pluripotent stem cells, optogenetics and microfabrication - and designed an open microdevice in which motor axons grow from a neural compartment containing embryonic stem cell-derived motor neurons and astrocytes through microchannels to form functional neuromuscular junctions with contractile myofibers in a separate compartment. Optogenetic entrainment of motor neurons in this reductionist neuromuscular circuit enhanced neuromuscular junction formation more than two-fold, mirroring the activity-dependence of synapse development in vivo. We incorporated an established motor neuron disease model into our system and found that coculture of motor neurons with SOD1G93A astrocytes resulted in denervation of the central compartment and diminished myofiber contractions, a phenotype which was rescued by the Receptor Interacting Serine/Threonine Kinase 1 (RIPK1) inhibitor Necrostatin. This coculture system replicates key aspects of nerve-muscle connectivity in vivo and represents a rapid and scalable alternative to animal models of neuromuscular function and disease.

Micronutrient and Amino Acid Losses During Renal Replacement Therapy for Acute Kidney Injury

Introduction

Malnutrition is common in patients with acute kidney injury (AKI), particularly in those requiring renal replacement therapy (RRT). Use of RRT removes metabolic waste products and toxins, but it will inevitably also remove useful molecules such as micronutrients, which might aggravate malnutrition. The RRT modalities vary in mechanism of solute removal; for example, intermittent hemodialysis (IHD) uses diffusion, continuous veno-venous hemofiltration (CVVH) uses convection, and sustained low-efficiency diafiltration (SLEDf) uses a combination of these.

Methods

We assessed micronutrient and amino acid losses in 3 different RRT modalities in patients with AKI (IHD, n = 27; SLEDf, n = 12; CVVH, n = 21) after correction for dialysis dose and plasma concentrations.

Results

Total losses were affected by modality; generally CVVH >> SLEDf > IHD (e.g., amino acid loss was 18.69 ± 3.04, 8.21 ± 4.07, and 5.13 ± 3.1 g, respectively; P < 0.001). Loss of specific trace elements (e.g., copper and zinc) during RRT was marked, with considerable heterogeneity between RRT types (e.g., +849 and +2325 μg/l lost during SLEDf vs. IHD, respectively), whereas effluent losses of copper and zinc decreased during CVVH (effect size relative to IHD, -3167 and -1442 μg/l, respectively). B vitamins were undetectable in effluent, but experimental modeling estimated 40% to 60% loss within the first 15 minutes of RRT.

Conclusion

Micronutrient and amino acid losses are marked during RRT in patients with AKI, with variation between RRT modalities and micronutrients.

Increase in CFC-11 emissions from eastern China based on atmospheric observations

The recovery of the stratospheric ozone layer relies on the continued decline in the atmospheric concentrations of ozone-depleting gases such as chlorofluorocarbons¹. The atmospheric concentration of trichlorofluoromethane (CFC-11), the second-most abundant chlorofluorocarbon, has declined substantially since the mid-1990s². A recently reported slowdown in the decline of the atmospheric concentration of CFC-11 after 2012, however, suggests that global emissions have increased^3,4. A concurrent increase in CFC-11 emissions from eastern Asia contributes to the global emission increase, but the location and magnitude of this regional source are unknown³. Here, using high-frequency atmospheric observations from Gosan, South Korea, and Hateruma, Japan, together with global monitoring data and atmospheric chemical transport model simulations, we investigate regional CFC-11 emissions from eastern Asia. We show that emissions from eastern mainland China are 7.0 ± 3.0 (±1 standard deviation) gigagrams per year higher in 2014-2017 than in 2008-2012, and that the increase in emissions arises primarily around the northeastern provinces of Shandong and Hebei. This increase accounts for a substantial fraction (at least 40 to 60 per cent) of the global rise in CFC-11 emissions. We find no evidence for a significant increase in CFC-11 emissions from any other eastern Asian countries or other regions of the world where there are available data for the detection of regional emissions. The attribution of any remaining fraction of the global CFC-11 emission rise to other regions is limited by the sparsity of long-term measurements of sufficient frequency near potentially emissive regions. Several considerations suggest that the increase in CFC-11 emissions from eastern mainland China is likely to be the result of new production and use, which is inconsistent with the Montreal Protocol agreement to phase out global chlorofluorocarbon production by 2010.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Continued Emissions of the Ozone-Depleting Substance Carbon Tetrachloride From Eastern Asia

Carbon tetrachloride (CCl₄) is an ozone-depleting substance, accounting for about 10% of the chlorine in the troposphere. Under the terms of the Montreal Protocol, its production for dispersive uses was banned from 2010. In this work we show that, despite the controls on production being introduced, CCl₄ emissions from the eastern part of China did not decline between 2009 and 2016. This finding is in contrast to a recent bottom-up estimate, which predicted a significant decrease in emissions after the introduction of production controls. We find eastern Asian emissions of CCl₄ to be 16 (9-24) Gg/year on average between 2009 and 2016, with the primary source regions being in eastern China. The spatial distribution of emissions that we derive suggests that the source distribution of CCl₄ in China changed during the 8-year study period, indicating a new source or sources of emissions from China's Shandong province after 2012.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Health Informatics 3.0 and other Increasingly Dispersed Technologies Require Even Greater Trust: Promoting Safe Evidence-based Health Informatics

Healthinformaticsisgenerallylesscommittedtoascientific evidence-basedapproach than any other area of health science, which is an unsound position. Introducing the new Web 3.0 paradigms into health IT applications can unleash a further great potential, able to integrate and distribute data from multiple sources. The counter sideisthatitmakestheuserandthepatientevermoredependentonthe

‘blackbox’ of the system, and the re-use of the data remote from the author and initial context. Thus anticipatory consideration of uses, and proactive analysis of evidenceof effects,are imperative,as only when a clinical technology can be proven to be trustworthy and safe should it be implementedwidely as is the case with other health technologies.

Toargueforpromotingevidence-basedhealthinformatics assystemsbecomemorepowerfulandpro-activeyetmoredispersed andremote;andevaluationasthemeansofgeneratingthenecessaryscientific evidencebase.TopresentongoingIMIAandEFMIinitiativesinthisfield.

Critical overview of recent developments in health informatics evaluation, alongside the precedents of other health technologies, summarising current initiatives and the new challenges presented by Health Informatics 3.0.

Web3.0should betaken asanopportunitytomovehealth informatics from being largely unaccountable to one of being an ethical andresponsiblescience-baseddomain.Recentandplannedactivities ofthe EFMIandIMIAworkinggroupshavesignificantlyprogressedkeyinitiatives.

Concurrent with the emergence of Web 3.0 as a means of new-generation diffuse health information systems comes an increasing need for an evidence-based culture in health informatics.

Evidence Based Health Informatics: 10 Years of Efforts to Promote the Principle

Objectives: To present the importance of Evidence-based Health Informatics (EBHI) and the ethical imperative of this approach; to highlight the work of the IMIA Working Group on Technology Assessment and Quality Improvement and the EFMI Working Group on Assessment of Health Information Systems; and to introduce the further important evaluation and evidence aspects being addressed.

Methods: Reviews of IMIA, EFMA and other initiatives, together with literature reviews on evaluation methods and on published systematic reviews.

Results: Presentation of the rationale for the health informatics domain to adopt a scientific approach by assessing impact, avoiding harm, and empirically demonstrating benefit and best use; reporting of the origins and rationale of the IMIA- and EQUATOR-endorsed Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI) and of the IMIA WG's Guideline for Good Evaluation Practice in Health Informatics (GEP-HI); presentation of other initiatives for objective evaluation; and outlining of further work in hand on usability and indicators; together with the case for development of relevant evaluation methods in newer applications such as telemedicine. The focus is on scientific evaluation as a reliable source of evidence, and on structured presentation of results to enable easy retrieval of evidence.

Conclusions: EBHI is feasible, necessary for efficiency and safety, and ethically essential. Given the significant impact of health informatics on health systems, care delivery and personal health, it is vital that cultures change to insist on evidence-based policies and investment, and that emergent global moves for this are supported.

Finding Ethical Principles and Practical Guidelines for the Controlled Flow of Patient Data

The application of computing to health care, and particularly to electronic patient records, offers major benefits but raises issues of confidentiality and of potential misuse. Sound access control mechanisms are therefore important, but most models focus upon informed consent by the data subject. This raises challenges in mental health care, and for other vulnerable patients including those comatose, and the severely ill and temporarily distressed. Published algorithms which are used to control record access within a controlled environment therefore have value, as a means of ensuring an open and informed, yet ethically sound, solution. The paper describes the background and issues, and gives an example of such an algorithm.

Systematic Prioritization of the STARE-HI Reporting Items

Background: We previously devised and published a guideline for reporting health informatics evaluation studies named STARE-HI, which is formally endorsed by IMIA and EFMI.

Objective: To develop a prioritization framework of ranked reporting items to assist authors when reporting health informatics evaluation studies in space restricted conference papers and to apply this prioritization framework to measure the quality of recent health informatics conference papers on evaluation studies.

Method: We deconstructed the STARE-HI guideline to identify reporting items. We invited a total of 111 authors of health informatics evaluation studies, reviewers and editors of health Informatics conference proceedings to score those reporting items on a scale ranging from “0 – not necessary in a conference paper” through to “10 – essential in a conference paper” by a web-based survey. From the responses we derived a mean priority score. All evaluation papers published in proceedings of MIE2006, Medinfo2007, MIE2008 and AMIA2008 were rated on these items by two reviewers. From these ratings a priority adjusted completeness score was computed for each paper.

Results: We identified 104 reporting items from the STARE-HI guideline. The response rate for the survey was 59% (66 out of 111). The most important reporting items (mean score ≥ 9) were “Interpret the data and give an answer to the study question – (in Discussion)”, “Whether it is a laboratory, simulation or field study – (in Methods-study design)” and “Description of the outcome measure/evaluation criteria – (in Methods-study design)”. Per reporting area the statistically more significant important reporting items were distinguished from less important ones. Four reporting items had a mean score ≤ 6. The mean priority adjusted completeness of evaluation papers of recent health informatics conferences was 48% (range 14 –78%).

Conclusion: We produced a ranked list of reporting items from STARE-HI according to their prioritized relevance for inclusion in space-limited conference papers. The priority adjusted completeness scores demonstrated room for improvement for the analyzed conference papers. We believe that this prioritization framework is an aid to improving the quality and utility of conference papers on health informatics evaluation studies.

Evaluation Considerations for Secondary Uses of Clinical Data: Principles for an Evidence-based Approach to Policy and Implementation of Secondary Analysis

Objectives: To set the scientific context and then suggest principles for an evidence-based approach to secondary uses of clinical data, covering both evaluation of the secondary uses of data and evaluation of health systems and services based upon secondary uses of data. Method: Working Group review of selected literature and policy approaches. Results: We present important considerations in the evaluation of secondary uses of clinical data from the angles of governance and trust, theory, semantics, and policy. We make the case for a multi-level and multi-factorial approach to the evaluation of secondary uses of clinical data and describe a methodological framework for best practice. We emphasise the importance of evaluating the governance of secondary uses of health data in maintaining trust, which is essential for such uses. We also offer examples of the re-use of routine health data to demonstrate how it can support evaluation of clinical performance and optimize health IT system design. Conclusions: Great expectations are resting upon "Big Data" and innovative analytics. However, to build and maintain public trust, improve data reliability, and assure the validity of analytic inferences, there must be independent and transparent evaluation. A mature and evidence-based approach needs not merely data science, but must be guided by the broader concerns of applied health informatics.

Distance-dependent gradient in NMDAR-driven spine calcium signals along tapering dendrites

Neurons receive a multitude of synaptic inputs along their dendritic arbor, but how this highly heterogeneous population of synaptic compartments is spatially organized remains unclear. By measuring N-methyl-d-aspartic acid receptor (NMDAR)-driven calcium responses in single spines, we provide a spatial map of synaptic calcium signals along dendritic arbors of hippocampal neurons and relate this to measures of synapse structure. We find that quantal NMDAR calcium signals increase in amplitude as they approach a thinning dendritic tip end. Based on a compartmental model of spine calcium dynamics, we propose that this biased distribution in calcium signals is governed by a gradual, distance-dependent decline in spine size, which we visualized using serial block-face scanning electron microscopy. Our data describe a cell-autonomous feature of principal neurons, where tapering dendrites show an inverse distribution of spine size and NMDAR-driven calcium signals along dendritic trees, with important implications for synaptic plasticity rules and spine function.

Behavioural adjustments of wild-caught kangaroos to captivity

It is important to understand how wild-caught animals may respond to captivity, and whether their behaviours in captivity are reflective of their wild counterparts. We observed the behaviour of wild-caught western grey kangaroos (Macropus fuliginosus) and red kangaroos (Osphranter rufus; formerly M. rufus) that were transferred to a large naturally vegetated enclosure. Observations were made on the first day of captivity and again after 7–10 days, and were compared with the behaviour of free-living kangaroos at the same locality and over the same period. We quantified feeding, moving, grooming and non-alert behaviours. Of these, grooming was higher in captive kangaroos than in free-living animals on the first day of captivity only, and was no different to that of wild animal by 7–10 days’ captivity. Such self-directed behaviour may be indicative of heightened distress for kangaroos on the first day of captivity, but it may also be indicative of grooming to eliminate contamination of human smells or debris following capture by darting and recovery. Overall, our findings indicate that after a short period of captivity, wild-caught kangaroos adjust to a novel environment relatively quickly, and animals from each species showed behaviour patterns comparable with free-ranging counterparts within 7–10 days after capture and captivity.

Assessing the trend in sustainable remediation: A questionnaire survey of remediation professionals in various countries

Over the past decade, sustainable remediation has grown from an emerging concept into a widely accepted new institutional norm. Scholar literature increased exponentially from nearly none in late 1990s to over 400 publications per year in 2014. The present study used a questionnaire survey conducted in 2012 and 2014 to assess the global trend in the awareness and practice of sustainable remediation. A total of 373 responses were received from survey participants located in 22 countries. The survey found that the US and the UK similarly had the highest level of awareness and adoption rate of sustainable remediation. Asia and other developing countries had much lower awareness levels and/or adoption rates. For all regions, the adoption rates were significantly lower than awareness levels, indicating a large gap between awareness and practice. One specific example is regarding minimizing greenhouse gas emission, which is a focal point in sustainable remediation literature, but with very low adoption rate according to this survey. This study also found that the adoption rates of a few sustainable remediation considerations, such as "minimizing local scale secondary impact", "minimizing national to global scale secondary impact", and "bringing prosperity to disadvantaged community", had decreased between 2012 and 2014. On the other hand, the survey also suggests the remediation community has rendered more expertise, training, and resources in sustainable remediation between 2012 and 2014. The mixed results suggest that in order to enhance sustainable remediation adoption, it is imperative to employ continued effort to enhance the understanding of sustainable remediation by practitioners and to link self-interest and public interest with sustainable remediation considerations.

Improving Evaluation to Address the Unintended Consequences of Health Information Technology:. a Position Paper from the Working Group on Technology Assessment & Quality Development

BACKGROUND AND OBJECTIVES

With growing use of IT by healthcare professionals and patients, the opportunity for any unintended effects of technology to disrupt care health processes and outcomes is intensified. The objectives of this position paper by the IMIA Working Group (WG) on Technology Assessment and Quality Development are to highlight how our ongoing initiatives to enhance evaluation are also addressing the unintended consequences of health IT.

METHODS

Review of WG initiatives Results: We argue that an evidence-based approach underpinned by rigorous evaluation is fundamental to the safe and effective use of IT, and for detecting and addressing its unintended consequences in a timely manner. We provide an overview of our ongoing initiatives to strengthen study design, execution and reporting by using evaluation frameworks and guidelines which can enable better characterization and monitoring of unintended consequences, including the Good Evaluation Practice Guideline in Health Informatics (GEP-HI) and the Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI). Indicators to benchmark the adoption and impact of IT can similarly be used to monitor unintended effects on healthcare structures, processes and outcome. We have also developed EvalDB, a web-based database of evaluation studies to promulgate evidence about unintended effects and are developing the content for courses to improve training in health IT evaluation.

CONCLUSION

Evaluation is an essential ingredient for the effective use of IT to improve healthcare quality and patient safety. WG resources and skills development initiatives can facilitate a proactive and evidence-based approach to detecting and addressing the unintended effects of health IT.

Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis

BACKGROUND

In Canada, 4,400 cases of oral cancer are diagnosed yearly. Surgical resection is a key component of treatment in many of these cancers. Reconstruction of defects, with the goal of preserving function, is of utmost importance. Several choices are possible for reconstruction of larger defects, including both free and pedicled flaps. Free flap reconstruction is reliable and effective, but requires additional personnel and peri-operative resources. Pedicled flaps remain an important alternative to free flaps, and are less resource intensive. This paper reviews our inaugural experience with the submental island flap (SIF) and compares costs incurred to a matched cohort of oral cancer patients reconstructed with forearm free flaps.

METHODS

Charts of patients who underwent SIF and RFFF reconstruction from January 1st 2013 to April 1st 2015 were retrospectively examined. Associated costs were obtained via online database and previously reported costs at the study institution.

RESULTS

Mean length of ICU stay in glossectomy RFFF reconstruction was 4.7 days. Only one patient required ICU stay for one night in the SIF group. Mean length of hospital stay was not significantly different in SIF patients vs RFFF patients (12.4 vs 15.4 days, p > 0.05). Mean operative time was significantly lower in the SIF group compared to the RFFF group (347 vs 552 min, p < 0.05). Total mean intraoperative costs were found to be $4780.59 for RFFF operations, versus $2307.94 for SIF. Total mean cost of post-operative stay was $18158.40 in the SIF group and $43617.60 in the RFFF group. Total cost savings were therefore $27931.85 per patient for the SIF group.

CONCLUSIONS

We have demonstrated the use of the submental island flap as an alternative to radial forearm free flaps, showing both decreased hospital costs and comparable patient outcomes. Pedicled flaps are making a resurgence in head and neck reconstruction, and the submental island flap offers an excellent alternative to more labour intensive and costly free flap alternatives.

Re-exposure to beta cell autoantigens in pancreatic allograft recipients with preexisting beta cell autoantibodies

Re-exposure to beta cell autoantigens and its relevance in the presence of donor-specific antibodies (DSA) in pancreatic allograft recipients is not well known. Thirty-three patients requiring a pancreas transplant were enrolled in an IRB approved study. They underwent prospective monitoring for DSA and beta cell autoantibody (BCAA) levels to GAD65, insulinoma-associated antigen 2 (IA-2), insulin (micro-IAA [mIAA]), and islet-specific zinc transporter isoform-8 (ZnT8). Twenty-five (75.7%) had pre-transplant BCAA. Twenty had a single antibody (mIAA n = 15, GAD65 n = 5); five had two or more BCAA (GAD65 + mIAA n = 2, GAD65 + mIAA+IA-2 n = 2, GA65 + mIAA+IA-2 + ZnT8 = 1). No changes in GAD65 (p > 0.29), IA-2 (>0.16), and ZnT8 (p > 0.07) were observed between pre-transplant and post-transplant at 6 or 12 months. A decrease in mIAA from pre- to post-6 months (p < 0.0001), 12 months (p < 0.0001), and from post-6 to post-12 months (p = 0.0002) was seen. No new BCAA was observed at one yr. Seven (21.0%) developed de novo DSA. The incidence of DSA was 24% in patients with BCAA vs. 25% in patients without BCAA (p = 0.69). Pancreatic allograft function of patients with vs. without BCAA, and with and without BCAA + DSA was comparable until last follow-up (three yr). Re-exposure to beta cell autoantigens by pancreas transplant may not lead to increased levels or development of new BCAA or pancreatic allograft dysfunction.

Optimising Health Informatics Outcomes--Getting Good Evidence to Where it Matters

This editorial is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Evidence-based Health informatics: How do we know what we know?", written by Elske Ammenwerth [1]. Health informatics uses and applications have crept up on health systems over half a century, starting as simple automation of large-scale calculations, but now manifesting in many cases as rule- and algorithm-based creation of composite clinical analyses and 'black box' computation of clinical aspects, as well as enablement of increasingly complex care delivery modes and consumer health access. In this process health informatics has very largely bypassed the rules of precaution, proof of effectiveness, and assessment of safety applicable to all other health sciences and clinical support systems. Evaluation of informatics applications, compilation and recognition of the importance of evidence, and normalisation of Evidence Based Health Informatics, are now long overdue on grounds of efficiency and safety. Ammenwerth has now produced a rigorous analysis of the current position on evidence, and evaluation as its lifeblood, which demands careful study then active promulgation. Decisions based on political aspirations, 'modernisation' hopes, and unsupported commercial claims must cease - poor decisions are wasteful and bad systems can kill. Evidence Based Health Informatics should be promoted, and expected by users, as rigorously as Cochrane promoted Effectiveness and Efficiency, and Sackett promoted Evidence Based Medicine - both of which also were introduced retrospectively to challenge the less robust and partially unsafe traditional 'wisdom' in vogue. Ammenwerth's analysis gives the necessary material to promote that mission.

Patient Portals as a Means of Information and Communication Technology Support to Patient- Centric Care Coordination - the Missing Evidence and the Challenges of Evaluation. A joint contribution of IMIA WG EVAL and EFMI WG EVAL

OBJECTIVES

To review the potential contribution of Information and Communication Technology (ICT) to enable patient-centric and coordinated care, and in particular to explore the role of patient portals as a developing ICT tool, to assess the available evidence, and to describe the evaluation challenges.

METHODS

Reviews of IMIA, EFMI, and other initiatives, together with literature reviews.

RESULTS

We present the progression from care coordination to care integration, and from patient-centric to person-centric approaches. We describe the different roles of ICT as an enabler of the effective presentation of information as and when needed. We focus on the patient's role as a co-producer of health as well as the focus and purpose of care. We discuss the need for changing organisational processes as well as the current mixed evidence regarding patient portals as a logical tool, and the reasons for this dichotomy, together with the evaluation principles supported by theoretical frameworks so as to yield robust evidence.

CONCLUSIONS

There is expressed commitment to coordinated care and to putting the patient in the centre. However to achieve this, new interactive patient portals will be needed to enable peer communication by all stakeholders including patients and professionals. Few portals capable of this exist to date. The evaluation of these portals as enablers of system change, rather than as simple windows into electronic records, is at an early stage and novel evaluation approaches are needed.

Citation analysis in health care sciences. Innovative investigation or seductive pseudo-science?

BACKGROUND

Citations of scientific papers in health care have become a subject of interest, as in any scientific sector. However, such a metric, while useful in a simple way, can become subject to too much credibility, and therefore to advanced analyses which are not soundly grounded even if methodologically valid.

OBJECTIVES

The objective was to contextualise citation indices in health care science, juxtaposed with a parallel analytic paper.

METHODS

The literature was reviewed and set against the objectives of metrics of literature and of researchers.

RESULTS

The strengths and weaknesses of citation indices in the health sector were identified, with practical examples of perverse effects, and compared with the core objectives of health care development.

CONCLUSIONS

Citation indices in health care science have a value, but this is limited to giving a broad overview. Other measures of effectiveness, including impact on education, on health care development, and on stimulation of applied developments, are needed rather than spuriously scientific advanced analyses of citation counts.

The RICHE taxonomy - an innovative means of classification of child health research

BACKGROUND

Research outputs increase inexorably. Health is now a required element in all policies of the European Union. There is a need for a system that helps to navigate the vast body of children's health research, identify pertinent research institutions, discover ongoing and recently funded research projects and identify gaps where there is little knowledge.

METHODS

The European Commission funded the Research Inventory of Child Health in Europe (RICHE) project through the Framework 7 Programme, to identify gaps in child health research in Europe. A necessary first step was to identify and index current research, for which a website repository was created. As a basis for this task, an innovative taxonomy was necessary to encompass the many arenas of children's health and development, including subjects outside the traditional areas of children's health. Drawing inspiration from existing taxonomies, library systems and other forms of classification, a multi-axial approach was selected as the best way to encompass the many influences on children's health. Six axes were identified and their contents defined. All of the axes can be viewed and searched independently, as well as in relation to each other. The axes encompass factors and service areas that impact on children, including health, education, justice, the environment and others. This has created a system that is consistent and impartial, but adaptable to an enormous variety of uses.

RESULTS

The taxonomy has been tested and validated by a number of well-respected academics, researchers and practitioners across Europe. It forms the basis of an intuitive and accessible database. This allows research knowledge to be easily identified and for networking to take place.

CONCLUSIONS

The RICHE taxonomy facilitates retrieval of knowledge - ongoing research as well as findings - in order to inform researchers and policy makers who wish to include children's health as an element of new policy.