An online system for calculating and delivering long-term carrying capacity information for Queensland grazing properties. Part 1: background and development

This paper (Part 1) describes the development of a new online system that estimates long-term carrying capacity (LTCC) for grazing properties across Queensland, Australia. High year-to-year and multi-year rainfall variability is a dominating feature of the climate of Queensland’s grazing lands, and poses major challenges for extensive livestock production. The use of LTCC is one approach used by graziers to reduce the impact of rainfall variability on land condition and financial performance. Over the past 30 years, scientists, graziers and their advisors have developed a simple approach to calculating LTCC ((average annual pasture growth × safe pasture utilisation) ÷ annual animal intake). This approach has been successful at a property scale (regional south-west Queensland) and in a wider application through Grazing Land Management (GLM) regional workshops. We have built on these experiences to develop an online system (as described in detail in Part 2; Zhang et al. 2021; this issue) that incorporates the simple LTCC approach with advances in technology and grazing science to provide LTCC information for Queensland grazing properties. Features of the LTCC system are: (1) assimilation of spatial datasets (cadastral data, grazing land types, climate data, remotely-sensed woody vegetation cover); (2) a pasture growth simulation model; (3) land type parameter sets of biophysical attributes; and (4) estimates of safe pasture utilisation. The ‘FORAGE LTCC report’ is a major product of the system, describing individual property information that allows detailed analysis and explanation of the components of the LTCC calculation by land type and land condition. The online system rapidly analyses property spatial data and calculates paddock/property LTCC information. For the 10 months between November 2020 and August 2021, over 4000 grazing property reports have been requested in Queensland, and has proven to be a sound basis for ‘discussion support’ with grazier managers and their advisors.

Modelling the Wolbachia incompatible insect technique: strategies for effective mosquito population elimination

BACKGROUND

The Wolbachia incompatible insect technique (IIT) shows promise as a method for eliminating populations of invasive mosquitoes such as Aedes aegypti (Linnaeus) (Diptera: Culicidae) and reducing the incidence of vector-borne diseases such as dengue, chikungunya and Zika. Successful implementation of this biological control strategy relies on high-fidelity separation of male from female insects in mass production systems for inundative release into landscapes. Processes for sex-separating mosquitoes are typically error-prone and laborious, and IIT programmes run the risk of releasing Wolbachia-infected females and replacing wild mosquito populations.

RESULTS

We introduce a simple Markov population process model for studying mosquito populations subjected to a Wolbachia-IIT programme which exhibit an unstable equilibrium threshold. The model is used to study, in silico, scenarios that are likely to yield a successful elimination result. Our results suggest that elimination is best achieved by releasing males at rates that adapt to the ever-decreasing wild population, thus reducing the risk of releasing Wolbachia-infected females while reducing costs.

CONCLUSIONS

While very high-fidelity sex separation is required to avoid establishment, release programmes tend to be robust to the release of a small number of Wolbachia-infected females. These findings will inform and enhance the next generation of Wolbachia-IIT population control strategies that are already showing great promise in field trials.

Can seawater desalination be a win-win fix to our water cycle?

While we increasingly turn to desalination as a secure water supply, it is still perceived as an expensive and environmentally damaging solution, affordable only for affluent societies. In this contribution, we recast desalination from one of a last resort to a far-reaching, climate change mitigating, water security solution. First, we argue that the benefits of desalination go beyond the single-use value of the water produced. If coupled with water reuse for irrigation, desalination reduces groundwater abstraction and augments the water cycle. As such, it may support both adaptation to, and mitigation of climate change impacts by deploying plentiful water for human use, with all the benefits that entails, while helping preserve and restore ecosystems. Second, we counter two arguments commonly raised against desalination, namely its environmental impact and high cost. The environmental impact can be fully controlled so as not to pose long-term threats, if driven by renewable energy. Desalination may then have a zero carbon footprint. Moreover, appropriately designed outfalls make the disposal of brine at sea compatible with marine ecosystems.. Recovery of energy, minerals and more water from brine reject (particularly in the form of vapour for cooling to enable more crops and vegetation to grow), while possible, is often hardly economically justified. However, resource recovery may become more attractive in the future, and help reduce the brine volumes to dispose of. When fresh water becomes scarce, its cost tends to go up, making desalination increasingly economic. Moreover, desalination can have virtually no environmental costs. Considering the environmental costs of over-abstraction of freshwater, desalination tilts the balance in its favour.

Self-Tracking, Social Media and Personal Health Records for Patient Empowered Self-Care

This paper explores the range of self-tracking devices and social media platforms used by the self-tracking community, and examines the implications of widespread adoption of these tools for scientific progress in health informatics.

A literature review was performed to investigate the use of social media and self-tracking technologies in the health sector. An environmental scan identified a range of products and services which were used to exemplify three levels of self-tracking: self-experimentation, social sharing of data and patient controlled electronic health records.

There appears to be an increase in the use of self-tracking tools, particularly in the health and fitness sector, but also used in the management of chronic diseases. Evidence of efficacy and effectiveness is limited to date, primarily due to the health and fitness focus of current solutions as opposed to their use in disease management.

Several key technologies are converging to produce a trend of increased personal health surveillance and monitoring, social connectedness and sharing, and integration of regional and national health information systems. These trends are enabling new applications of scientific techniques, from personal experimentation to e-epidemiology, as data gathered by individuals are aggregated and shared across increasingly connected healthcare networks. These trends also raise significant new ethical and scientific issues that will need to be addressed, both by health informatics researchers and the communities of self-trackers themselves.

Towards Addressing the Opportunities and Challenges of Web 2.0 for Health and Informatics

ObjectiveTo provide an overview of Web 2.0 and Health 2.0, and so facilitate a widespread discussion of the nature of these concepts and their possible application within the health domain, and implications for health and biomedical informatics and for IMIA.

MethodsIMIA, the International Medical Informatics Association, has established a Web 2.0 Exploratory Taskforce to bring together interested individuals from within and outside IMIA to explore the nature and potential of Web 2.0 applications. The Taskforce aims to develop background materials and sample uses of Web 2.0 applications, so as to propose specific lines of action for the IMIA Board and General Assembly. This paper provides a brief overview of Web 2.0 and related concepts, and examples of general and health-specific Web 2.0 applications. Some examples of the issues, challenges and opportunities are introduced, to set the scene for a wider dialogue on if, how, and how best, IMIA, and the wider health and informatics communities, should use these new applications and approaches.

Results and conclusionsThis brief paper provides an introduction to, and overview of, the many issues involved in considering the application of Web 2.0 to health and informatics. All interested individuals and organisations are invited to use this as a starting point for engaging in wider discussion and contributing to the Taskforce and to IMIA’s future.

Experience in the Use of Social Media in Medical and Health Education

Social media are online tools that allow collaboration and community building. Succinctly, they can be described as applications where “users add value”. This paper aims to show how five educators have used social media tools in medical and health education to attempt to add value to the education they provide.

We conducted a review of the literature about the use of social media tools in medical and health education. Each of the authors reported on their use of social media in their educational projects and collaborated on a discussion of the advantages and disadvantages of this approach to delivering educational projects.

We found little empirical evidence to support the use of social media tools in medical and health education. Social media are, however, a rapidly evolving range of tools, websites and online experiences and it is likely that the topic is too broad to draw definitive conclusions from any particular study. As practitioners in the use of social media, we have recognised how difficult it is to create evidence of effectiveness and have therefore presented only our anecdotal opinions based on our personal experiences of using social media in our educational projects.

The authors feel confident in recommending that other educators use social media in their educational projects. Social media appear to have unique advantages over non-social educational tools. The learning experience appears to be enhanced by the ability of students to virtually build connections, make friends and find mentors. Creating a scientific analysis of why these connections enhance learning is difficult, but anecdotal and preliminary survey evidence appears to be positive and our experience reflects the hypothesis that learning is, at heart, a social activity.

What side effects are problematic for patients prescribed antipsychotic medication? The Maudsley Side Effects (MSE) measure for antipsychotic medication

BACKGROUND

Capturing service users' perspectives can highlight additional and different concerns to those of clinicians, but there are no up to date, self-report psychometrically sound measures of side effects of antipsychotic medications. Aim To develop a psychometrically sound measure to identify antipsychotic side effects important to service users, the Maudsley Side Effects (MSE) measure.

METHOD

An initial item bank was subjected to a Delphi exercise (n = 9) with psychiatrists and pharmacists, followed by service user focus groups and expert panels (n = 15) to determine item relevance and language. Feasibility and comprehensive psychometric properties were established in two samples (N43 and N50). We investigated whether we could predict the three most important side effects for individuals from their frequency, severity and life impact.

RESULTS

MSE is a 53-item measure with good reliability and validity. Poorer mental and physical health, but not psychotic symptoms, was related to side-effect burden. Seventy-nine percent of items were chosen as one of the three most important effects. Severity, impact and distress only predicted 'putting on weight' which was more distressing, more severe and had more life impact in those for whom it was most important.

CONCLUSIONS

MSE is a self-report questionnaire that identifies reliably the side-effect burden as experienced by patients. Identifying key side effects important to patients can act as a starting point for joint decision making on the type and the dose of medication.

The Role of Free/Libre and Open Source Software in Learning Health Systems

Objective: To give an overview of the role of Free/Libre and Open Source Software (FLOSS) in the context of secondary use of patient data to enable Learning Health Systems (LHSs). Methods: We conducted an environmental scan of the academic and grey literature utilising the MedFLOSS database of open source systems in healthcare to inform a discussion of the role of open source in developing LHSs that reuse patient data for research and quality improvement. Results: A wide range of FLOSS is identified that contributes to the information technology (IT) infrastructure of LHSs including operating systems, databases, frameworks, interoperability software, and mobile and web apps. The recent literature around the development and use of key clinical data management tools is also reviewed. Conclusions: FLOSS already plays a critical role in modern health IT infrastructure for the collection, storage, and analysis of patient data. The nature of FLOSS systems to be collaborative, modular, and modifiable may make open source approaches appropriate for building the digital infrastructure for a LHS.

Correction: Visualising mouse neuroanatomy and function by metal distribution using laser ablation-inductively coupled plasma-mass spectrometry imaging

Correction for ‘Visualising mouse neuroanatomy and function by metal distribution using laser ablation-inductively coupled plasma-mass spectrometry imaging’ by Bence Paul et al., Chem. Sci., 2015, 6, 5383–5393.

BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment

Excess deaths from cardiovascular disease are a major contributor to the significant reduction in life expectancy experienced by people with schizophrenia. Important risk factors in this are smoking, alcohol misuse, excessive weight gain and diabetes. Weight gain also reinforces service users' negative views of themselves and is a factor in poor adherence with treatment. Monitoring of relevant physical health risk factors is frequently inadequate, as is provision of interventions to modify these. These guidelines review issues surrounding monitoring of physical health risk factors and make recommendations about an appropriate approach. Overweight and obesity, partly driven by antipsychotic drug treatment, are important factors contributing to the development of diabetes and cardiovascular disease in people with schizophrenia. There have been clinical trials of many interventions for people experiencing weight gain when taking antipsychotic medications but there is a lack of clear consensus regarding which may be appropriate in usual clinical practice. These guidelines review these trials and make recommendations regarding appropriate interventions. Interventions for smoking and alcohol misuse are reviewed, but more briefly as these are similar to those recommended for the general population. The management of impaired fasting glycaemia and impaired glucose tolerance ('pre-diabetes'), diabetes and other cardiovascular risks, such as dyslipidaemia, are also reviewed with respect to other currently available guidelines.These guidelines were compiled following a consensus meeting of experts involved in various aspects of these problems. They reviewed key areas of evidence and their clinical implications. Wider issues relating to primary care/secondary care interfaces are discussed but cannot be resolved within guidelines such as these.

Ultra-high-precision Nd-isotope measurements of geological materials by MC-ICPMS

We report novel techniques allowing the measurement of Nd-isotope ratios with unprecedented accuracy and precision by multi-collector inductively coupled plasma mass spectrometry. Using the new protocol, we have measured the Nd-isotopic composition of rock and synthetic Nd standards as well as that of the Allende carbonaceous chondrite. Analyses of BCR-2, BHVO-2 and GSP-2 rock standards yield mass-independent compositions identical to the JNdi-1 Nd-reference standard, with an external reproducibility of 2.4, 1.6, 1.6 and 3.5 ppm respectively, on μ142Nd, μ145Nd, μ146Nd and μ150Nd (μ representing the ppm-deviation of the ratios from JNdi-1) using 148Nd/144Nd for internal normalization. This represents an improvement in precision by a factor of 2, 7 and 9 respectively for μ142Nd, μ145Nd and μ150Nd. Near-quantitative recovery from purification chemistry and sample-standard bracketing allow for the determination of mass-dependent Nd-isotopic composition of samples. Synthetic standards, namely La Jolla and AMES, record mass-dependent variability of up to 1.2 ε per atomic mass unit and mass-independent compositions resolvable by up to 3 ppm for μ142Nd and 8 ppm for μ150Nd, relative to JNdi-1. The mass-independent compositions are consistent with equilibrium mass fractionation during purification. The terrestrial rock standards define a uniform stable ε145Nd of -0.24 ± 0.19 (2SD) relative to JNdi-1, indistinguishable from the mean Allende ε145Nd of -0.19 ± 0.09. We consider this value to represent the mass-dependent Nd-isotope composition of Bulk Silicate Earth (BSE). The modest mass-dependent fractionation of JNdi-1 relative to BSE results in potential effects on mass-independent composition that cannot be resolved within the reproducibility of our analyses when correcting for natural and instrumental mass fractionation by kinetic law, making it a suitable reference standard for analysis of unknowns. Analysis of Allende (CV3) carbonaceous chondrite returns an average μ142Nd deficit of -30.1 ± 3.7 ppm in agreement with previous studies. The apparent deficit is, however, lowered to -23.8 ± 4.0 ppm while normalizing to 148Nd/144Nd instead of 146Nd/144Nd. We interpret this as the effect of a possible nucleosynthetic anomaly of -6.3 ± 0.5 ppm in μ146Nd. As 142Nd and 146Nd are both s-process-dominated nuclides, this hints at the possibility that terrestrial μ142Nd excess may not reflect 146Sm decay as widely accepted.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Correction: Visualising mouse neuroanatomy and function by metal distribution using laser ablation-inductively coupled plasma-mass spectrometry imaging

Correction for 'Visualising mouse neuroanatomy and function by metal distribution using laser ablation-inductively coupled plasma-mass spectrometry imaging' by Bence Paul et al., Chem. Sci., 2015, DOI: 10.1039/c5sc02231b.

Screening for the metabolic side effects of antipsychotic medication: findings of a 6-year quality improvement programme in the UK

OBJECTIVES

To increase the frequency and quality of screening for the metabolic syndrome in people prescribed continuing antipsychotic medication.

DESIGN

An audit-based, quality improvement programme (QIP) with customised feedback to participating mental health services after each audit, including benchmarked data on their relative and absolute performance against an evidence-based practice standard and the provision of bespoke change interventions.

SETTING

Adult, assertive outreach, community psychiatric services in the UK.

PARTICIPANTS

6 audits were conducted between 2006 and 2012. 21 mental health Trusts participated in the baseline audit in 2006, submitting data on screening for 1966 patients, while 32 Trusts participated in the 2012 audit, submitting data on 1591 patients.

RESULTS

Over the 6 years of the programme, there was a statistically significant increase in the proportion of patients for whom measures for all 4 aspects of the metabolic syndrome had been documented in the clinical records in the previous year, from just over 1 in 10 patients in 2006 to just over 1 in 3 by 2012. The proportion of patients with no evidence of any screening fell from almost ½ to 1 in 7 patients over the same period.

CONCLUSIONS

The findings suggest that audit-based QIPs can help improve clinical practice in relation to physical healthcare screening. Nevertheless, they also reveal that only a minority of community psychiatric patients prescribed antipsychotic medication is screened for the metabolic syndrome in accordance with best practice recommendations, and therefore potentially remediable causes of poor physical health remain undetected and untreated.

Tungsten isotopes in bulk meteorites and their inclusions-Implications for processing of presolar components in the solar protoplanetary disk

We present high precision, low- and high-resolution tungsten isotope measurements of iron meteorites Cape York (IIIAB), Rhine Villa (IIIE), Bendego (IC), and the IVB iron meteorites Tlacotepec, Skookum, and Weaver Mountains, as well as CI chondrite Ivuna, a CV3 chondrite refractory inclusion (CAI BE), and terrestrial standards. Our high precision tungsten isotope data show that the distribution of the rare p-process nuclide ¹⁸⁰W is homogeneous among chondrites, iron meteorites, and the refractory inclusion. One exception to this pattern is the IVB iron meteorite group, which displays variable excesses relative to the terrestrial standard, possibly related to decay of rare ¹⁸⁴Os. Such anomalies are not the result of analytical artifacts and cannot be caused by sampling of a protoplanetary disk characterized by p-process isotope heterogeneity. In contrast, we find that ¹⁸³W is variable due to a nucleosynthetic s-process deficit/r-process excess among chondrites and iron meteorites. This variability supports the widespread nucleosynthetic s/r-process heterogeneity in the protoplanetary disk inferred from other isotope systems and we show that W and Ni isotope variability is correlated. Correlated isotope heterogeneity for elements of distinct nucleosynthetic origin (¹⁸³W and ⁵⁸Ni) is best explained by thermal processing in the protoplanetary disk during which thermally labile carrier phases are unmixed by vaporization thereby imparting isotope anomalies on the residual processed reservoir.

Visualising mouse neuroanatomy and function by metal distribution using laser ablation-inductively coupled plasma-mass spectrometry imaging

Studying the neuroanatomy of the mouse brain using imaging mass spectrometry and chemometric analysis.

Metals have a number of important roles within the brain. We used laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) to map the three-dimensional concentrations and distributions of transition metals, in particular iron (Fe), copper (Cu) and zinc (Zn) within the murine brain. LA-ICP-MS is one of the leading analytical tools for measuring metals in tissue samples. Here, we present a complete data reduction protocol for measuring metals in biological samples, including the application of a pyramidal voxel registration technique to reproducibly align tissue sections. We used gold (Au) nanoparticle and ytterbium (Yb)-tagged tyrosine hydroxylase antibodies to assess the co-localisation of Fe and dopamine throughout the entire mouse brain. We also examined the natural clustering of metal concentrations within the murine brain to elucidate areas of similar composition. This clustering technique uses a mathematical approach to identify multiple ‘elemental clusters’, avoiding user bias and showing that metal composition follows a hierarchical organisation of neuroanatomical structures. This work provides new insight into the distinct compartmentalisation of metals in the brain, and presents new avenues of exploration with regard to region-specific, metal-associated neurodegeneration observed in several chronic neurodegenerative diseases.

Evidence for nucleosynthetic enrichment of the protosolar molecular cloud core by multiple supernova events

The presence of isotope heterogeneity of nucleosynthetic origin amongst meteorites and their components provides a record of the diverse stars that contributed matter to the protosolar molecular cloud core. Understanding how and when the solar system's nucleosynthetic heterogeneity was established and preserved within the solar protoplanetary disk is critical for unraveling the earliest formative stages of the solar system. Here, we report calcium and magnesium isotope measurements of primitive and differentiated meteorites as well as various types of refractory inclusions, including refractory inclusions (CAIs) formed with the canonical ²⁶Al/²⁷Al of ~5 × 10^-5 (²⁶Al decays to ²⁶Mg with a half-life of ~0.73 Ma) and CAIs that show fractionated and unidentified nuclear effects (FUN-CAIs) to understand the origin of the solar system's nucleosynthetic heterogeneity. Bulk analyses of primitive and differentiated meteorites along with canonical and FUN-CAIs define correlated, mass-independent variations in ⁴³Ca, ⁴⁶Ca and ⁴⁸Ca. Moreover, sequential dissolution experiments of the Ivuna carbonaceous chondrite aimed at identifying the nature and number of presolar carriers of isotope anomalies within primitive meteorites have detected the presence of multiple carriers of the short-lived ²⁶Al nuclide as well as carriers of anomalous and uncorrelated ⁴³Ca, ⁴⁶Ca and ⁴⁸Ca compositions, which requires input from multiple and recent supernovae sources. We infer that the solar system's correlated nucleosynthetic variability reflects unmixing of old, galactically-inherited homogeneous dust from a new, supernovae-derived dust component formed shortly prior to or during the evolution of the giant molecular cloud parental to the protosolar molecular cloud core. This implies that similarly to ⁴³Ca, ⁴⁶Ca and ⁴⁸Ca, the short-lived ²⁶Al nuclide was heterogeneously distributed in the inner solar system at the time of CAI formation.

Big Data in Science and Healthcare: A Review of Recent Literature and Perspectives. Contribution of the IMIA Social Media Working Group

OBJECTIVES

As technology continues to evolve and rise in various industries, such as healthcare, science, education, and gaming, a sophisticated concept known as Big Data is surfacing. The concept of analytics aims to understand data. We set out to portray and discuss perspectives of the evolving use of Big Data in science and healthcare and, to examine some of the opportunities and challenges.

METHODS

A literature review was conducted to highlight the implications associated with the use of Big Data in scientific research and healthcare innovations, both on a large and small scale.

RESULTS

Scientists and health-care providers may learn from one another when it comes to understanding the value of Big Data and analytics. Small data, derived by patients and consumers, also requires analytics to become actionable. Connectivism provides a framework for the use of Big Data and analytics in the areas of science and healthcare. This theory assists individuals to recognize and synthesize how human connections are driving the increase in data. Despite the volume and velocity of Big Data, it is truly about technology connecting humans and assisting them to construct knowledge in new ways. Concluding Thoughts: The concept of Big Data and associated analytics are to be taken seriously when approaching the use of vast volumes of both structured and unstructured data in science and health-care. Future exploration of issues surrounding data privacy, confidentiality, and education are needed. A greater focus on data from social media, the quantified self-movement, and the application of analytics to "small data" would also be useful.

The challenges of publishing on health informatics in developing countries

The Journal of Health Informatics in Developing Countries was established to meet a perceived need for Health Informaticians in developing countries to be able to share the results of their research in an affordable and easy-to-access online publication. The journal was developed using the open source platform "Open Journal System," and has now published 67 articles across 13 issues. A collaborative editorial approach has been established to address the problems of limited research budgets, difficulties with translating to English and other problems specific to authors from developing countries. The journal faces many challenges including ensuring future financial sustainability and inclusion in journal indexing systems. However, the continuing support of an international body of Associate Editors and Editorial Board Members has enabled a wide range of useful and informative health informatics research to be disseminated across the developing world.

Comparison of 2 portable respiratory gas analysers

The aim of this study was to compare respiratory measures taken simultaneously using the Cosmed K4b(2) and Cortex Metamax II portable metabolic systems. 10 trained male cyclists performed a graded exercise cycle test to exhaustion (40w.3 min (- 1)) under standardized conditions. The measured respiratory variables were significantly correlated between both devices: r=0.97 and 0.98 (n=10, p<0.01) for oxygen uptake ( V˙O(2)) and ventilation (VE), respectively. Further Bland and Altman plots revealed a good level of agreement for measures of V˙O(2) expressed in mL.min (- 1) [- 670 to 486] (mean bias of - 91.7, i. e., - 3.1%) or in mL.min (- 1).kg (- 1) [- 7.3 to 9.0] (mean bias of 0.85, i. e., 2.3%) and V(E) [- 23.1 to 18.2] (L.min (- 1), mean bias of - 2.4, i. e. - 4.1%). However, poor agreement was found for measures of carbon dioxide (VCO(2), mL.min (- 1)) [- 280 to 1 394] (mean bias of 671 i.e., 20.3%). VCO(2) at maximal exercise intensity was also significantly (p<0.01) greater in the Cortex compared to the Cosmed system. The higher measured CO(2) concentrations led to significantly (p<0.01) higher calculated respiratory exchange ratio (RER) values with the Cortex device. In conclusion, there was satisfactory agreement between the Cosmed K4b(2) and Cortex Metamax II systems for most respiratory measures; however there was a poor level of agreement between VCO(2) and calculated RER measurements between the 2 systems.

Self-Tracking, Social Media and Personal Health Records for Patient Empowered Self-Care. Contribution of the IMIA Social Media Working Group

OBJECTIVES

This paper explores the range of self-tracking devices and social media platforms used by the self-tracking community, and examines the implications of widespread adoption of these tools for scientific progress in health informatics.

METHODS

A literature review was performed to investigate the use of social media and self-tracking technologies in the health sector. An environmental scan identified a range of products and services which were used to exemplify three levels of self-tracking: self-experimentation, social sharing of data and patient controlled electronic health records.

RESULTS

There appears to be an increase in the use of self-tracking tools, particularly in the health and fitness sector, but also used in the management of chronic diseases. Evidence of efficacy and effectiveness is limited to date, primarily due to the health and fitness focus of current solutions as opposed to their use in disease management.

CONCLUSIONS

Several key technologies are converging to produce a trend of increased personal health surveillance and monitoring, social connectedness and sharing, and integration of regional and national health information systems. These trends are enabling new applications of scientific techniques, from personal experimentation to e-epidemiology, as data gathered by individuals are aggregated and shared across increasingly connected healthcare networks. These trends also raise significant new ethical and scientific issues that will need to be addressed, both by health informatics researchers and the communities of self-trackers themselves.

Medication prescribed to people with personality disorder: the influence of patient factors and treatment setting

OBJECTIVE

To examine the extent of use and clinical rationale for the prescribing of psychotropic drugs for people with personality disorder (PD) who are in contact with mental health services.

METHOD

Clinical records of 278 patients with a primary diagnosis of PD were examined.

RESULTS

Just over 80% (N = 225) of patients were being prescribed psychotropic medication. One in five was prescribed three or more drugs. People with comorbid mental disorders were more likely to receive psychotropic medication. Half those prescribed antidepressants had no record of depression in their records. While drug treatments were mostly prescribed for depressive and psychotic symptoms, they were also used to try to manage behavioural problems such as self-harm or given in response to patient requests for treatment. People receiving specialist PD services (OR = 0.35, 95% CI = 0.13-0.95) or other specialist services (OR = 0.24, 95% CI = 0.10-0.60) were less likely to be prescribed drug treatments.

CONCLUSION

Drug treatments are widely used for people with PD despite the relatively weak evidence base. Both the type of personality problem and the context in which treatment is delivered appear to have an impact on whether drug treatments are prescribed.

Nature and quality of antipsychotic prescribing practice in UK psychiatry of intellectual disability services

BACKGROUND

Antipsychotics are perceived to be over-used in the management of behavioural problems in people with an intellectual disability (ID). Published guidelines have set good practice standards for the use of these drugs for behavioural indications. We sought to identify the range of indications for which antipsychotic drugs are prescribed in people with ID and to audit clinical practice against the standards.

METHOD

Data were collected from the clinical records of individuals with ID who were under the care of mental health services in the UK, and prescribed an antipsychotic drug.

RESULTS

The sample comprised 2319 patients from 39 clinical services. Twenty-seven per cent of the patients had a diagnosis of a psychotic illness (ICD-10 F20-29) and 27% an affective illness (ICD-10 F30-39). The proportion who did not have a psychiatric diagnosis ranged from 6% of those with borderline/mild ID to 21% of those with severe/profound ID. Overall, the most common indications for prescribing an antipsychotic drug were comorbid psychotic illness, anxiety and agitation, and a range of behavioural disturbances. The prevalence of use of antipsychotic drugs to manage challenging behaviour in the absence of concomitant mental illness increased with the severity of ID and accounted for almost half of prescriptions in those with severe/profound ID. Adherence to the audit standards related to documentation of clinical indications and review of efficacy was high. Side effect monitoring was less assiduous.

CONCLUSIONS

In clinical practice, most prescriptions for antipsychotic drugs in people with ID are consistent with the evidence base and the overall quality of prescribing practice, as measured against recognised standards, is good, although in some patients potentially remedial side effects may not be detected and treated.

Experience in the use of social media in medical and health education. Contribution of the IMIA Social Media Working Group

OBJECTIVES

Social media are online tools that allow collaboration and community building. Succinctly, they can be described as applications where "users add value". This paper aims to show how five educators have used social media tools in medical and health education to attempt to add value to the education they provide.

METHODS

We conducted a review of the literature about the use of social media tools in medical and health education. Each of the authors reported on their use of social media in their educational projects and collaborated on a discussion of the advantages and disadvantages of this approach to delivering educational projects.

RESULTS

We found little empirical evidence to support the use of social media tools in medical and health education. Social media are, however, a rapidly evolving range of tools, websites and online experiences and it is likely that the topic is too broad to draw definitive conclusions from any particular study. As practitioners in the use of social media, we have recognised how difficult it is to create evidence of effectiveness and have therefore presented only our anecdotal opinions based on our personal experiences of using social media in our educational projects.

CONCLUSION

The authors feel confident in recommending that other educators use social media in their educational projects. Social media appear to have unique advantages over non-social educational tools. The learning experience appears to be enhanced by the ability of students to virtually build connections, make friends and find mentors. Creating a scientific analysis of why these connections enhance learning is difficult, but anecdotal and preliminary survey evidence appears to be positive and our experience reflects the hypothesis that learning is, at heart, a social activity.

Treadmill Velocity Best Predicts 5000-m Run Performance

In this study, we aimed to investigate physiological determinants of endurance performance that best predict 5000-m average run velocity before and after endurance training. Thirty-nine previously untrained participants completed a 5000-m run; a constant velocity test (measuring running economy); and an incremental treadmill test to determine maximal oxygen uptake, final treadmill velocity, and velocity and oxygen uptake at lactate threshold, before and after six weeks of endurance training. Maximal oxygen uptake, final treadmill velocity, and velocity and oxygen uptake at threshold all increased significantly after training (p < 0.05). Average velocity for 5000 m increased significantly (p < 0.05). Running economy was not significantly altered. Correlation analysis revealed final treadmill velocity was most strongly related to 5000-m performance, in both untrained and trained states (r = 0.89, 0.83). Lactate threshold velocity (r = 0.73, 0.76), maximal oxygen uptake (r = 0.55, 0.51) and oxygen uptake at threshold (r = 0.45, 0.45) also showed significant correlations. In contrast, running economy was not significantly related to performance. These results demonstrate that final treadmill velocity in an VO2max test is the single best predictor of 5000-m performance in untrained and trained states. Furthermore, stepwise regression analysis showed that only velocity at lactate threshold significantly improved the accuracy of prediction provided by final treadmill velocity alone.

Screening for the metabolic syndrome in community psychiatric patients prescribed antipsychotics: a quality improvement programme

OBJECTIVE

The aim was to evaluate a quality improvement programme designed to increase screening for the metabolic syndrome in community psychiatric patients prescribed antipsychotics.

METHOD

Baseline audit against evidence-based standards, followed by provision of benchmarked data and a range of change interventions, with re-audit 1 year later.

RESULTS

At baseline, 48 assertive outreach teams across the UK submitted data on screening over the previous year for 1966 patients. At re-audit, 35 of the teams submitted data for 1516 patients. Screening for all four aspects of the metabolic syndrome (measuring blood pressure, obesity, blood glucose and plasma lipids) had increased significantly by re-audit. Clinical variables increasing the likelihood of full screening were clozapine treatment and a known diagnosis of diabetes or dyslipidaemia.

CONCLUSION

The programme's success may be partly attributed to the use of a widely-accepted audit standard, and bespoke change interventions that directly addressed barriers to screening identified by the participating clinical teams.

Towards addressing the opportunities and challenges of Web 2.0 for health and informatics

OBJECTIVE

To provide an overview of Web 2.0 and Health 2.0, and so facilitate a widespread discussion of the nature of these concepts and their possible application within the health domain, and implications for health and biomedical informatics and for IMIA.

METHODS

IMIA, the International Medical Informatics Association, has established a Web 2.0 Exploratory Taskforce to bring together interested individuals from within and outside IMIA to explore the nature and potential of Web 2.0 applications. The Taskforce aims to develop background materials and sample uses of Web 2.0 applications, so as to propose specific lines of action for the IMIA Board and General Assembly. This paper provides a brief overview of Web 2.0 and related concepts, and examples of general and health-specific Web 2.0 applications. Some examples of the issues, challenges and opportunities are introduced, to set the scene for a wider dialogue on if, how, and how best, IMIA, and the wider health and informatics communities, should use these new applications and approaches.

RESULTS AND CONCLUSIONS

This brief paper provides an introduction to, and overview of, the many issues involved in considering the application of Web 2.0 to health and informatics. All interested individuals and organisations are invited to use this as a starting point for engaging in wider discussion and contributing to the Taskforce and to IMIA's future.

Managing diabetes mellitus in patients with advanced cancer: a case note audit and guidelines

Patients with advanced cancer and diabetes mellitus present a challenge to healthcare professionals. To establish how diabetes is currently being managed in these patients, we audited the care of patients who died in Cheltenham General Hospital over the previous 12 months with diagnoses of both diabetes mellitus and cancer. Management and monitoring of the diabetes was variable and there was little record of discussion between healthcare professionals and the patient or family regarding the diabetes. Thirty-two out of 42 patients continued to have blood sugar monitoring up to and including the day they died. We review the literature on this topic and suggest guidelines to help professionals to appropriately manage diabetes in the palliative setting at the end of life.

Obesity, dyslipidaemias and smoking in an inpatient population treated with antipsychotic drugs

OBJECTIVE

The prevalence of cardiovascular disease in people with schizophrenia is known to be above population norms. In addition, many antipsychotic drugs have been associated with weight gain and some with dyslipidaemia. Our aims were to determine the apparent and actual prevalence of the modifiable risk factors for cardiovascular disease: obesity, hyperlipidaemia and smoking, in hospitalized patients treated with antipsychotic drugs.

METHOD

(i) Survey of clinical notes. (ii) Direct measurement of fasting lipids, body mass index and waist : hip ratio.

RESULTS

Lipids were rarely monitored and body weight often not recorded making the apparent prevalence of these cardiovascular risk factors low. Smoking status was recorded. When directly measured, the actual prevalence of obesity was above population norms and two-thirds of patients had a dyslipidaemia.

CONCLUSION

Routine screening for these modifiable risk factors followed by active intervention where appropriate could significantly reduce morbidity and mortality in this patient group.

The use of prescribing indicators to measure the quality of care in psychiatric inpatients

OBJECTIVE

To explore the potential for using seven prescribing indicators, individually and in combination, to measure prescribing quality for hospitalised psychiatric patients.

DESIGN AND SETTING

The dataset included full details of all psychotropic medication prescribed over a 24 hour period to 4192 inpatients in 49 British mental health services in 1998.

RESULTS

Despite the large size of the dataset, for three of the indicators 20 services had fewer than 10 eligible patients. There was great variation between services in indicator scores. Correlations between standardised indicator scores and total score (which omitted the indicator concerned) were above 0.3 for all but one of the indicators. Cronbach's alpha was 0.73 when this outlying indicator was removed.

CONCLUSIONS

There are no routinely collected prescribing data that allow for the quality of prescribing for psychiatric patients to be monitored. Six of the seven indicators measured during this census survey appear to reflect a common attribute of the services, and the analysis suggests that they might be combined to give an overall measure of service performance. There was, however, no relationship between performance on the seventh indicator and performance on the other six. This raises questions about case mix and service level factors that might influence indicator scores independent of prescriber decision making. The psychometric properties of prescribing indicators (occurrence rates, consistency over time) are unknown.

Mobile medics? The mobility of doctors in the European Economic Area

The Treaty of Rome seeks to generate a common European market whereby all barriers to the free movement of produce, capital, services and labour are removed. Current EU policy on the free movement of labour requires that healthcare workers, who are EU citizens and meet certain training criteria, have the right to register to practice in member states other than the one in which they trained. This policy is underpinned by the EEC Directives. For example, the Medical Directive 93/16/EEC describes the framework for the mutual recognition of medical diplomas, certificates and other evidence of qualifications through out the European Economic Area (EEA). The potential impact of this for health policy is clear-workforce planning and the demand for doctors, (and also nurses and other health care professionals), could be particularly affected by new forces impacting on their supply. This paper reports on the reality of labour mobility today, and on the factors upon which mobility depends, by the means of a case study which, investigated the movement into UK of doctors from the EEA. At a formal level there is mutual recognition of diplomas, certificates and other evidence of qualifications. However, formal and 'real life' recognition could be in tension equating in policy terms to an implementation deficit. As a result, there is a 'mixed picture' which makes predicting the future (both for individual countries and for the European Union) even more difficult. Furthermore, different policy objectives have to be reconciled. Do we want high mobility; or do we want to preserve national manpower planning?

Association of educational achievement with pulsatile arterial diameter change of the common carotid artery: the Atherosclerosis Risk in Communities (ARIC) Study, 1987-1992

Education is strongly inversely associated with common carotid artery intima-media thickness in the Atherosclerosis Risk in Communities (ARIC) Study. The authors extended the ARIC study of preclinical atherosclerosis by evaluating the cross-sectional association of education with common carotid artery elasticity. This study included 10,091 Black and White men and women aged 45-64 years who were free of clinical coronary heart disease and stroke/transient ischemic attack. Arterial elasticity was assessed by pulsatile arterial diameter change (PADC), derived from phase-locked echo-tracking. The smaller the PADC, the stiffer the artery. Education was categorized into grade school, high school without graduation, high school with graduation, vocational school, some college, and graduate/professional school. PADC was directly associated with educational attainment. The mean PADCs, adjusted for age, height, diastolic diameter, systolic blood pressure, pulse pressure (linear and squared), ethnicity, gender, and smoking status, in successively higher education strata were 402 (standard error (SE) 5), 403 (SE 4), 407 (SE 3), 413 (SE 4), 416 (SE 2), and 417 (SE 4) microm (p = 0.007). To the authors' knowledge, this is the first time such an association has been reported. If arterial dilation impairment precedes arterial wall thickening in the atherosclerotic process, as recent studies on endothelial dysfunction suggest, these results indicate that low socioeconomic status may be associated with early arterial pathophysiologic changes-an effect that appears to be mediated by established cardiovascular disease risk factors.

Survey of new antidepressants in secondary care

INTRODUCTION

There are no conclusive data to support the superior efficacy of any one antidepressant, while costs and side-effects are known to differ. The use of venlafaxine has been observed to be increasing within local services and this is associated with significant cost. This survey examined the patterns of use of new antidepressants by psychiatrists in the UK.

METHOD

188 questionnaires were sent to hospital pharmacists. The doses of fluoxetine, paroxetine, sertraline and venlafaxine used for the treatment of depression over a 1-week census period were recorded, together with the total quantities of each drug supplied by hospital pharmacies in the financial year 1997/1998.

RESULTS

84 completed replies were received (45%), with a total number of 2060 prescriptions for depression, making this the largest survey to date of antidepressant prescribing by psychiatrists. Fluoxetine and paroxetine were associated with less dosage titration and cost less per treatment month than sertraline and venlafaxine.

CONCLUSION

Venlafaxine has not been consistently proven to be more effective than other antidepressants and is more costly, yet its use by psychiatrists is increasing nationally. Comparative data such as these are not routinely available for hospital care in the UK. The new NHS will bring more demand for such data and more accountability for its content. (Int J Psych Clin Pract 2000; 4:105-109).

Hostility, social support, and coronary heart disease in the National Heart, Lung, and Blood Institute Family Heart Study

This cross-sectional study investigated the association of hostility and social support to coronary heart disease (CHD) in 2 groups of men and women: those with a familial predisposition for CHD (high-risk sample) and a randomly selected group. The hypothesis was that hostility and low social support would be associated with CHD, and would have a greater effect in the high-risk group. The random sample contained 2,447 individuals (47.1% male) from 576 families, and the high-risk sample consisted of 2,300 people (45.5% male) from 542 families. Odds ratios (OR) and their 95% confidence intervals were calculated using generalized estimating equations (GEE) for logistic regression. Family was specified as the clustering variable, and robust SEEs were obtained to account for dependence of the data within families. After controlling for age, education, body mass index, exercise, smoking history, drinking history, and drinking >5 drinks a day, hostility was associated with a history of coronary bypass surgery or coronary angioplasty in high-risk men (OR 1.21) and a history of myocardial infarction in high-risk women (OR 1.39). High-risk women with high social support had reduced odds of a previous myocardial infarction (OR 0.76), whereas women with high network adequacy in the random sample had reduced risk of myocardial infarction (OR 0.41) and angina (OR 0.49). A ratio of high hostility to low social support was associated with past myocardial infarction in high-risk women (OR 2.47) and a history of angina (OR 2.02) in the random sample men. These results suggest that high hostility and low social support are associated with some manifestations of CHD after controlling for adverse health behaviors.

Workforce planning. Catching the drift

NHS workforce planning has traditionally ignored the role of doctors and nurses trained in continental Europe and Scandinavia. At present doctors trained in the European Economic Area make up 10 per cent of senior house officers in England and Wales. But the numbers coming to the UK are falling. Falling medical unemployment in Europe will mean these doctors have less incentive to come to the UK, leaving a considerable gap in the NHS workforce. More local research is needed into working patterns and career plans of European-trained nurses and doctors.

Familial history of stroke and stroke risk. The Family Heart Study

BACKGROUND AND PURPOSE

Although familial history of stroke is generally perceived to be an important marker of stroke risk, very few epidemiological studies have been published to address this hypothesis. We sought to examine whether familial history of stroke is associated with the prevalence of stroke in the Family Heart Study, a National Heart, Lung, and Blood Institute-supported multicenter study of the familial, genetic, and nongenetic determinants of cardiovascular disease in populations.

METHODS

The personal and familial histories of stroke were assessed in 3168 individuals (probands) who were at least 45 years old and 29,325 of their first-degree relatives with the use of a standardized questionnaire.

RESULTS

The age-, ethnicity-, and sex-adjusted stroke prevalences were 4.8%, 4.9%, and 3.9% in probands with a positive familial, paternal, and maternal history of stroke, respectively, in comparison with 2.0% in probands without any positive familial history (P < .01). The age-, ethnicity-, and sex-adjusted odds ratios (95% confidence interval) of stroke were 2.00 (1.13, 3.54) for a positive paternal and 1.41 (0.80, 2.50) for a positive maternal history of stroke. Additional statistical adjustment for the proband's history of elevated cholesterol level, cigarette smoking status, history of coronary heart disease, hypertension, and diabetes did not alter the associations. A similar pattern was seen for African Americans and European Americans.

CONCLUSIONS

The increased risk of stroke among persons with a positive familial history of stroke compared with those without a familial history of stroke is consistent with the expression of genetic susceptibility, a shared environment, or both in the etiology of stroke.

Necessary conditions for a socialist health service

A socialist health service in a non-socialist society may be forced to stress care and rescue rather than prevention, health maintenance or the promotion of better health and more equal health status. A socialist health service ought to be 'integrated'. A socialist health service ought to provide universal and comprehensive care.

NHS reforms. Counting the costs

Localism predominates in purchaser-provider relationships, with markets strictly limited in practice. Block contracting predominates, largely to enable purchasers to bring pressure to bear on providers' costs and outputs. The administrative costs of operating the purchaser-provider split have led to a clear growth in the overall administrative costs within the NHS. Locality commissioning may conflict with the need to reorganise clinical services.