Data quality in European primary care research databases. Report of a workshop held in London September 2013

Primary care research databases provide a significant resource for health services and epidemiological research. However since data are recorded primarily for clinical care their suitability for research may vary widely according to the research application or recording practices of individual general practitioners. A methodological approach for characterising data quality is required. We describe a one-day workshop entitled “Towards a common protocol for measuring and monitoring data quality in European primary care research databases”. Researchers, database experts and clinicians were invited to give their perspectives on data quality and to exchange ideas on what data quality metrics should be made available to researchers. We report the main outcomes of this workshop, including a summary of the presentations and discussions and suggested way forward

Integrating Behavioral Health & Primary Care in New Hampshire: A Path Forward to Sustainable Practice & Payment Transformation

New Hampshire residents face challenges with behavioral and physical health conditions and the interplay between them. National studies show the costs and the burden of illness from behavioral health conditions and co-occurring chronic health conditions that are not adequately treated in either primary care or behavioral health settings. Bringing primary health and behavioral health care together in integrated care settings can improve outcomes for both behavioral and physical health conditions. Primary care integrated behavioral health works in conjunction with specialty behavioral health providers, expanding capacity, improving access, and jointly managing the care of patients with higher levels of acuity In its work to improve the health of NH residents and create effective and cost-effective systems of care, the NH Citizens Health Initiative (Initiative) created the NH Behavioral Health Integration Learning Collaborative (BHI Learning Collaborative) in November of 2015, as a project of its Accountable Care Learning Network (NHACLN). Bringing together more than 60 organizations, including providers of all types and sizes, all of the state’s community mental health centers, all of the major private and public insurers, and government and other stakeholders, the BHI Learning Collaborative built on earlier work of a NHACLN Workgroup focused on improving care for depression and co-occurring chronic illness. The BHI Learning Collaborative design is based on the core NHACLN philosophy of “shared data and shared learning” and the importance of transparency and open conversation across all stakeholder groups. The first year of the BHI Learning Collaborative programming included shared learning on evidence-based practice for integrated behavioral health in primary care, shared data from the NH Comprehensive Healthcare Information System (NHCHIS), and work to develop sustainable payment models to replace inadequate Fee-for-Service (FFS) revenues. Provider members joined either a Project Implementation Track working on quality improvement projects to improve their levels of integration or a Listen and Learn Track for those just learning about Behavioral Health Integration (BHI). Providers in the Project Implementation Track completed a self-assessment of levels of BHI in their practice settings and committed to submit EHR-based clinical process and outcomes data to track performance on specified measures. All providers received access to unblinded NHACLN Primary Care and Behavioral Health attributed claims data from the NHCHIS for provider organizations in the NH BHI Learning Collaborative. Following up on prior work focused on developing a sustainable model for integrating care for depression and co-occurring chronic illness in primary care settings, the BHI Learning Collaborative engaged consulting experts and participants in understanding challenges in Health Information Technology and Exchange (HIT/HIE), privacy and confidentiality, and workforce adequacy. The BHI Learning Collaborative identified a sustainable payment model for integrated care of depression in primary care. In the process of vetting the payment model, the BHI Learning Collaborative also identified and explored challenges in payment for Substance Use Disorder Screening, Brief Intervention and Referral to Treatment (SBIRT). New Hampshire’s residents will benefit from a health care system where primary care and behavioral health are integrated to support the care of the whole person. New Hampshire’s current opiate epidemic accentuates the need for better screening for behavioral health issues, prevention, and treatment referral integrated into primary care. New Hampshire providers and payers are poised to move towards greater integration of behavioral health and primary care and the Initiative looks forward to continuing to support progress in supporting a path to sustainable integrated behavioral and primary care

A pragmatic approach for measuring data quality in primary care databases

There is currently no widely recognised methodology for undertaking data quality assessment in electronic health records used for research. In an attempt to address this, we have developed a protocol for measuring and monitoring data quality in primary care research databases, whereby practice-based data quality measures are tailored to the intended use of the data. Our approach was informed by an in-depth investigation of aspects of data quality in the Clinical Practice Research Datalink Gold database and presentations of the results to data users. Although based on a primary care database, much of our proposed approach would be equally applicable to other health care databases

A comparison of the antimicrobial efficacy of silver diamine fluoride and silver nitrate: an in vitro study

A COMPARISON OF THE ANTIMICROBIAL EFFICACY OF SILVER DIAMINE FLUORIDE AND SILVER NITRATE: AN IN VITRO STUDY By: Nicholas L Luke, D.D.S. A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Dentistry at Virginia Commonwealth University. Virginia Commonwealth University, May 2018 Thesis Advisor: William O. Dahlke Jr., D.M.D. Pediatric Dentistry, Department Chair Purpose: To determine the antimicrobial efficacy of SDF and SN/NaF. Methods: Three bacterial species were combined to create an in vitro biofilm. Treatment was completed with SN, SN/NaF, SDF, SDF½ or untreated (control). Results: The untreated group demonstrated significantly higher growth than all other treatment groups across the study. On the BHI-plates (1-day), there were significant differences between all treatments except SDF and SDF½. On the BHI-plates (3-days), SN/NaF was not significantly different from SDF or SDF½. On the L-MRS-plates (1-day), both SN treatment groups yielded significantly higher growth than the SDF groups. On the L-MRS-plates (3-days), SN yielded significantly higher growth than SN/NaF, SDF, and SDF½. Conclusion: SDF is more effective than SN/NaF, with the exception of BHI-plates (3-days) only and SN/NaF is more effective than SN on primarily S. mutans and L. acidophilus. There is evidence of a possible antimicrobial tolerance of oral bacteria to silver

Willingness to Pay for Social Health Insurance among Informal Sector Workers in Wuhan, China: a Contingent Valuation Study

Background: Most of the about 140 million informal sector workers in urban China do not have health insurance. A 1998 central government policy leaves it to the discretion of municipal governments to offer informal sector workers in cities voluntary participation in a social health insurance for formal sector workers, the so-called 'basic health insurance' (BHI). Methods: We used the contingent valuation method to assess the maximum willingness to pay (WTP) for BHI among informal sector workers, including unregistered rural-to-urban migrants, in Wuhan City, China. We selected respondents in a two-stage self-weighted cluster sampling scheme. Results: On average, informal sector workers were willing to pay substantial amounts for BHI (30 Renminbi (RMB), 95% confidence interval (CI) 27-33) as well as substantial proportions of their incomes (4.6%, 95% CI 4.1-5.1%). Average WTP increased significantly when any one of the copayments of the BHI was removed in the valuation: to 51 RMB (95% CI 46-56) without reimbursement ceiling; to 43 RMB (95% CI 37-49) without deductible; and to 47 RMB (95% CI 40-54) without coinsurance. WTP was higher than estimates of the cost of BHI based on past health expenditure or on premium contributions of formal sector workers. Predicted coverage with BHI declined steeply with the premium contribution at low contribution levels. When we applied equity weighting in the aggregation of individual WTP values in order to adjust for inequity in the distribution of income, mean WTP for BHI increased with inequality aversion over a plausible range of the aversion parameter. Holding other factors constant in multiple regression analysis, for a 1% increase in income WTP for BHI with different copayments increased by 0.434-0.499% (all p < 0.0001), and for a 1% increase in past health care expenditure WTP increased by 0.076-0.148% (all p < 0.0004). Being male, a migrant, or without permanent employment significantly decreased WTP for BHI. Education was not a significant determinant of WTP for BHI. Conclusion: Our results suggest that Chinese municipal governments should allow informal sector workers to participate in the BHI. From a normative perspective, BHI for informal sector workers is likely to increase social welfare because average WTP for BHI is significantly higher than estimates of the average cost of BHI. We further find that informal sector workers do not value the BHI as a mechanism to recover the relatively frequent but small financial losses associated with common illnesses, but because it protects against the rare but large financial losses associated with catastrophic care. From a behavioural perspective, our results predict that at a price equal to the average premium contribution of formal sector workers 35% of informal sector workers will enrol in the BHI. Subsidies and changes in insurance attributes (e.g. including catastrophic care and portability) should be effective in increasing BHI coverage. In addition, coverage should expand with rising incomes among informal sector workers in China. Finally, adverse selection will be unlikely to be a large problem, if the BHI is offered to informal sector workers

Foodborne Staphylococcus Aureus: Identification and Enterotoxin Production in Milk and Cheese.

Onemocnění z potravin (alimentární onemocnění) vyvolaná bakteriemi jsou stále aktuálním tématem v celosvětovém měřítku. Abychom zajistili výrobu zdravotně nezávadných potravin, je potřeba nových poznatků o virulenci patogenů, které by doplnily již známé skutečnosti o jejich růstu a přeživání v potravinách. Také potřebujeme vyvíjet rychlé a citlivé metody na detekci těchto patogenů. Dizertační práce popisuje metodu na detekci S. aureus v potravinách, která je založená na PCR v reálném čase ve spojení s namnožením v selektivním médium. Dále pojednává o vlivu environmentálních faktorů na růst S. aureus a tvorbu enterotoxinů v mléce a sýrech. Vyvinuli jsme rychlou a citlivou metodu na detekci S. aureus v potravinách s použitím selektivního namnožení a PCR v reálném čase. Nově vyvinutá metoda umožnila detekci S. aureus na druhý den od přijetí vzorku. Tato metoda může být použita jako rychlejší, citlivějsí a vysoce specifická alternativní metoda ke konvenční mikrobiologické metodě. Zkoumali jsme vliv tří různých teplot, 8°C, 12°C a 20°C na růst S. aureus a tvorbu enterotoxinu D v pasterizovaném mléce a na růst, expresi genu sed a tvorbu enterotoxinu D v tekutém médiu s extraktem z mozku a srdce (BHI). Experimenty byly prováděny v malých skleněných fermentorech po 6 dní. Genová exprese byla sledována pomocí qRT-PCR a tvorba enterotoxinu D byla měřena pomocí imunologické metody ELISA. Růstová křivka v BHI měla stejný průběh při 20°C a 12°C, ale v při 12°C začal růst se spožděním. Při 8°C nebyl pozorován žádný růst. Růst S. aureus v mléce byl ve srovnání s BHI menší. sed mRNA byla detekována při 20°C po 4 hodinách a při 12°C po 7 hodinách a produkce enterotoxinu se objevila v exponenciální fázi růstu. V mléce se produkce SED při 20°C a při 12°C objevila dříve, ale celkové množství vyprodukovaného SED bylo nižší než v BHI. Při 8°C nebyla pozorována žádná produkce SED stejně jako v BHI. Dále byl zkoumán společný vliv nízké teploty 12°C a přítomnosti kompetitivní doprovodné mikroflóry pocházející ze surového mléka na růst S. aureus a produkci enterotoxinu v pasterizovaném mléce. Byl pozorován inhibiční účinek na růst a produkci enterotoxinů a vliv kompetice byl výraznější než vliv nízké teploty. Produkce enterotoxinu byla nízká a odpovídala růstu. Snížením množství doprovodné mikroflóry a zvýšením inokula došlo pouze k nepatrnému zvýšení produkce enterotoxinu. V další fázi byly dva různé typy sýrů zaočkovány S. aureus za účelem simulace sekundární kontaminace při výrobě sýrů. Vzorky byly odebírány v průběhu 4 týdnů. Kritické faktory jako jsou kompetitivní mikrofóra nebo pH, které jsou zodpovědné za regulaci virulence S. aureus byly sledovány. Snažili jsem se rozlišit situace při kterých: (i) není pozorován růst, ale objevuje se produkce enterotoxinu a (ii) dochází k růstu ale bez produkce enterotoxinu.Foodborne diseases caused by bacteria are an actual issue worldwide. To produce food, which is safe for human consumption, data about food-borne pathogen virulence is required to complement the already existing knowledge about the bacterial growth and survival in food. There is also a growing need for rapid and sensitive methods to detect these pathogens. In this dissertation, the real-time PCR-based method for the detection of S. aureus in food using selective enrichment and the impact of environmental factors on S. aureus growth and enterotoxin production in milk and cheese are described. We developed a rapid and sensitive method for the detection of S. aureus in food using selective enrichment and a new species-specific real-time PCR. The method facilitated the detection of S. aureus on the next day after the sample reception. This method can be used for S. aureus detection as a faster, highly specific, and more sensitive alternative to the microbiological method. We investigated the effect of three different temperatures, 8°C, 12°C and 20°C on S. aureus growth and SED production in pasteurized milk and on growth, sed gene expression and SED production in Brain heart infusion. The experiments were performed in small-scale fermentors for six days and gene expression was followed by qRT-PCR. SED production was measured using Enzyme-Linked ImmunoSorbent Assay (ELISA). In BHI the growth pattern was the same at 20°C and 12°C but delayed in the latter. At 8°C there was no growth. In milk, growth was lower compared to BHI. sed mRNA was detected at 20°C and 12°C after 4 and 7 hours respectively in BHI and the production occurred during the exponential phase of growth. In milk the SED production at 20°C and 12°C occurred earlier in growth but a lower total amount was produced compared to BHI. At 8°C, there was no SED production like in BHI. The combined effect of low temperature, 12°C, and the presence of competing background microflora derived from raw milk on the growth of S. aureus and SED production in pasteurized milk was further investigated. An inhibitory effect on S. aureus growth and enterotoxin production was observed and the impact of competition was greater than the impact of low temperature. The enterotoxin production was low and correlated with the growth. By lowering the amount of competing microflora and increasing the inoculation level of S. aureus, only a slight increase in enterotoxin production occurred. In the next stage, two different cheese matrices were inoculated with S. aureus to simulate a post-contamination scenario in cheese manufacture. Samples were collected over period of 4 weeks. Critical food factors, like competing microflora and pH, which are responsible for down- and up-regulation of the virulence of S. aureus, were monitored. We tried to indentify if there are situations in which: (i) no growth but enterotoxin formation is observed, and (ii) growth and no enterotoxin formation occurs.

Host and bacterial proteases influence biofilm formation and virulence in a murine model of enterococcal catheter-associated urinary tract infection

Urinary tract infections: targeting enzymes might help Identifying bacterial and host enzymes that support biofilm formation may help prevent urinary tract infections caused by catheters. Enterococcus faecalis bacteria is a leading cause of catheter-associated urinary tract infections, the most common type of hospital-acquired infections. Michael Caparon and colleagues at Washington University School of Medicine in Missouri, USA, studied these infections in mice. They examined the effects of two protein-degrading enzymes, both from the bacterium and one can be activated by urine trypsin-like protease from the animals. Mutations that impaired either one of the enzymes had no effect on the infection, but when both the bacterial enzymes were impaired by mutation the formation of biofilms was significantly reduced. Treating the mice with chemicals that inhibited both bacterial and host enzymes dramatically reduced catheter-induced inflammation and related problems. This suggests drugs targeting these enzymes could be useful in clinical care

Effect of Faecalibacterium prausnitzii on intestinal barrier function and immune homeostasis : a dissertation presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science, Massey University, Manawatū, New Zealand

Various gastrointestinal (GI) diseases, for example inflammatory bowel disease, are linked to impaired barrier function, chronic inflammation and dysbiosis of the resident microbiota. Faecalibacterium prausnitzii, an abundant obligate anaerobe of the healthy human microbiota, has reduced abundance in the GI tract of people with these diseases, and has been suggested to exert beneficial effects. Only a few studies have investigated its mechanisms of action, partly due to the difficulty of co-culturing live obligate anaerobes with oxygen-requiring human cells. The novel apical anaerobic co-culture model used in this study allows this co-culture through the separation of anaerobic and aerobic compartments. This model was used to investigate the effects of live F. prausnitzii (strains A2-165, ATCC 27768 and HTF-F) on intestinal barrier integrity, measured by transepithelial electrical resistance (TEER) of the intestinal epithelial cell line Caco-2, and on immune homeostasis, specifically on Toll-like receptor (TLR) activation. Method development was required to adapt these assays to the novel model and to optimise the growth of F. prausnitzii co-cultured with Caco-2 cells and TLR-expressing cell lines while maintaining their viabilities. Firstly, the optimised co-culture conditions were used to determine the effect of the three F. prausnitzii strains on barrier integrity of healthy and tumour necrosis factor alpha (TNF-α) treated Caco-2 cells. Live and growing F. prausnitzii did not alter the TEER across healthy Caco-2 cells. However, under TNF-α mediated inflammatory conditions, dead F. prausnitzii decreased TEER, whereas live bacteria maintained TEER. Secondly, the TLR activation assay was adapted to be carried out in the novel model. Using the adapted assay conditions it was determined that live F. prausnitzii induced greater TLR2 and TLR2/6 activation than dead F. prausnitzii. Collectively, these results indicate greater immuno-stimulatory effects of live F. prausnitzii, via TLR2 activation, and this effect is potentially linked to its barrier maintaining properties, because previous research showed enhancement of barrier integrity induced by TLR2 signalling. This new knowledge contributes to the understanding of how F. prausnitzii may maintain immune homeostasis in the GI tract. Unravelling the biological mechanisms used by prevalent species of the human microbiota, such as F. prausnitzii, will ultimately allow better comprehension of microbial regulation of GI function