Adherence in paediatric respiratory medicine: A review of the literature

Poor adherence is an important factor in unstable disease control and treatment failure. There are multiple ways to monitor a patient’s adherence, each with their own advantages and disadvantages. The reasons for poor adherence are multi-factorial, inter-related and often difficult to target for improvement. Although practitioners can implement different methods of adherence, the ultimate aim is to improve health outcomes for the individual and the health care system. Asthma is a common airway disease, particularly diagnosed in children, often treated with inhaled corticosteroids and long-acting bronchodilators. Due to the disease’s tendency for exacerbations and consequently, when severe will require unscheduled health care utilisation including hospital admissions, considerable research has been done into the effects of medication adherence on asthma control. This review discusses the difficulties in defining adherence, the reasons for and consequences of poor adherence, and the methods of recording and improving adherence in asthma patients, including an in-depth analysis of the uses of smart inhalers

Lightweight Object Detection Ensemble Framework for Autonomous Vehicles in Challenging Weather Conditions

The computer vision systems driving autonomous vehicles are judged by their ability to detect objects and obstacles in the vicinity of the vehicle in diverse environments. Enhancing this ability of a self-driving car to distinguish between the elements of its environment under adverse conditions is an important challenge in computer vision. For example, poor weather conditions like fog and rain lead to image corruption which can cause a drastic drop in object detection (OD) performance. The primary navigation of autonomous vehicles depends on the effectiveness of the image processing techniques applied to the data collected from various visual sensors. Therefore, it is essential to develop the capability to detect objects like vehicles and pedestrians under challenging conditions such as like unpleasant weather. Ensembling multiple baseline deep learning models under different voting strategies for object detection and utilizing data augmentation to boost the models' performance is proposed to solve this problem. The data augmentation technique is particularly useful and works with limited training data for OD applications. Furthermore, using the baseline models significantly speeds up the OD process as compared to the custom models due to transfer learning. Therefore, the ensembling approach can be highly effective in resource-constrained devices deployed for autonomous vehicles in uncertain weather conditions. The applied techniques demonstrated an increase in accuracy over the baseline models and were able to identify objects from the images captured in the adverse foggy and rainy weather conditions. The applied techniques demonstrated an increase in accuracy over the baseline models and reached 32.75% mean average precision (mAP) and 52.56% average precision (AP) in detecting cars in the adverse fog and rain weather conditions present in the dataset. The effectiveness of multiple voting strategies for bounding box predictions on the dataset is also demonstrated. These strategies help increase the explainability of object detection in autonomous systems and improve the performance of the ensemble techniques over the baseline models

A simulation tool for better management of retinal services

Background: Advances in the management of retinal diseases have been fast-paced as new treatments become available, resulting in increasing numbers of patients receiving treatment in hospital retinal services. These patients require frequent and long-term follow-up and repeated treatments, resulting in increased pressure on clinical workloads. Due to limited clinic capacity, many National Health Service (NHS) clinics are failing to maintain recommended follow-up intervals for patients receiving care. As such, clear and robust, long term retinal service models are required to assess and respond to the needs of local populations, both currently and in the future. Methods: A discrete event simulation (DES) tool was developed to facilitate the improvement of retinal services by identifying efficiencies and cost savings within the pathway of care. For a mid-size hospital in England serving a population of over 500,000, we used 36 months of patient level data in conjunction with statistical forecasting and simulation to predict the impact of making changes within the service. Results: A simulation of increased demand and a potential solution of the 'Treat and Extend' (T&E) regimen which is reported to result in better outcomes, in combination with virtual clinics which improve quality, effectiveness and productivity and thus increase capacity is presented. Without the virtual clinic, where T&E is implemented along with the current service, we notice a sharp increase in the number of follow-ups, number of Anti-VEGF injections, and utilisation of resources. In the case of combining T&E with virtual clinics, there is a negligible (almost 0%) impact on utilisation of resources. Conclusions: Expansion of services to accommodate increasing number of patients seen and treated in retinal services is feasible with service re-organisation. It is inevitable that some form of initial investment is required to implement service expansion through T&E and virtual clinics. However, modelling with DES indicates that such investment is outweighed by cost reductions in the long term as more patients receive optimal treatment and retain vision with better outcomes. The model also shows that the service will experience an average of 10% increase in surplus capacity.Peer reviewedFinal Published versio

MRC ORACLE Children Study. Long term outcomes following prescription of antibiotics to pregnant women with either spontaneous preterm labour or preterm rupture of the membranes

BACKGROUND: The Medical Research Council (MRC) ORACLE trial evaluated the use of co-amoxiclav 375 mg and/or erythromycin 250 mg in women presenting with preterm rupture of membranes (PROM) ORACLE I or in spontaneous preterm labour (SPL) ORACLE II using a factorial design. The results showed that for women with a singleton baby with PROM the prescription of erythromycin is associated with improvements in short term neonatal outcomes, although co-amoxiclav is associated with prolongation of pregnancy, a significantly higher rate of neonatal necrotising enterocolitis was found in these babies. Prescription of erythromycin is now established practice for women with PROM. For women with SPL antibiotics demonstrated no improvements in short term neonatal outcomes and are not recommended treatment. There is evidence that both these conditions are associated with subclinical infection so perinatal antibiotic administration may reduce the risk of later disabilities, including cerebral palsy, although the risk may be increased through exposure to inflammatory cytokines, so assessment of longer term functional and educational outcomes is appropriate. METHODS: The MRC ORACLE Children's Study will follow up UK children at age 7 years born to 4809 women with PROM and the 4266 women with SPL enrolled in the earlier ORACLE trials. We will use a parental questionnaire including validated tools to assess disability and behaviour. We will collect the frequency of specific medical conditions: cerebral palsy, epilepsy, respiratory illness including asthma, diabetes, admission to hospital in last year and other diseases, as reported by parents. National standard test results will be collected to assess educational attainment at Key Stage 1 for children in England. DISCUSSION: This study is designed to investigate whether or not peripartum antibiotics improve health and disability for children at 7 years of age. TRIAL REGISTRATION: The ORACLE Trial and Children Study is registered in the Current Controlled Trials registry. ISCRTN 52995660

Quantum Frame Relativity of Subsystems, Correlations and Thermodynamics

It was recently noted that different internal quantum reference frames (QRFs) partition a system in different ways into subsystems, much like different inertial observers in special relativity decompose spacetime in different ways into space and time. Here we expand on this QRF relativity of subsystems and elucidate that it is the source of all novel QRF dependent effects, just like the relativity of simultaneity is the origin of all characteristic special relativistic phenomena. We show that subsystem relativity, in fact, also arises in special relativity with internal frames and, by implying the relativity of simultaneity, constitutes a generalisation of it. Physical consequences of the QRF relativity of subsystems, which we explore here systematically, and the relativity of simultaneity may thus be seen in similar light. We focus on investigating when and how subsystem correlations and entropies, interactions and types of dynamics (open vs. closed), as well as quantum thermodynamical processes change under QRF transformations. We show that thermal equilibrium is generically QRF relative and find that, remarkably, $\textit{QRF transformations not only can change a subsystem temperature, but even map positive into negative temperature states}$. We further examine how non-equilibrium notions of heat and work exchange, as well as entropy production and flow depend on the QRF. Along the way, we develop the first study of how reduced subsystem states transform under QRF changes. Focusing on physical insights, we restrict to ideal QRFs associated with finite abelian groups. Besides being conducive to rigour, the ensuing finite-dimensional setting is where quantum information-theoretic quantities and quantum thermodynamics are best developed. We anticipate, however, that our results extend qualitatively to more general groups and frames, and even to subsystems in gauge theory and gravity.Comment: 49 pages + appendices, 12 figures. Comments welcom

A national survey of diagnostic tests reported by UK community optometrists for the detection of chronic open angle glaucoma

Purpose:  In the UK, the majority of cases of chronic open angle glaucoma are detected by community optometrists following a routine sight test. However, there is potential for variability in case finding strategies used. The aim of this study was to carry out a national web-based survey to determine current diagnostic tests used by optometrists in glaucoma case finding. / Methods:  Optometrists on the Association of Optometrists (AOP) electronic database were invited to participate. The survey was open for 16 weeks between April and July 2008. / Results:  A total of 1875 optometrists were eligible to enter the survey, of which 1264 answered the questions relating to diagnostic equipment. Respondents were asked to indicate their usual method of examining the optic nerve head. Direct ophthalmoscopy only was used by 25% with the majority (62%) using a combination of direct and slit-lamp binocular indirect methods. The vast majority of optometrists (78%) used non-contact tonometry to measure intraocular pressure, with only 16% routinely using a Goldmann or Perkins applanation tonometer. The perimeter most frequently used was either one of the Henson range of instruments (39%) or the Humphrey Field Analyser (22%). A smaller number of optometrists (<5%) had access to more specialised imaging equipment, such as HRT, GDx or OCT. / Conclusions:  The results of the survey demonstrate that UK optometrists are well equipped to carry out case finding for chronic open angle glaucoma, although there is a lack of standardisation with respect to equipment used

Standing Balance Stability and the Effects of Light Touch in Adults With Profound Loss of Vision-An Exploratory Study

Purpose: We evaluated the postural stability of adults with inherited profound vision loss and examined the effects of touch on their balance control. Methods: A total of 11 severely-sight impaired patients (mean [SD] age, 51.6 [5.3] years) and 11 control subjects (mean age, 49.7 [5.3] years) participated. Postural stability was measured using a force-balance platform eyes open/closed on a firm/foam surface under 3 test conditions: no touch, light touch, and unrestricted touch (UT), where "touch" involved placing their index finger on a rigid table. Average magnitude of center of foot pressure displacement was calculated. A somatosensory ratio (SR) was used to evaluate the somatosensory contribution to balance. A repeated measures ANOVA was used to investigate the effects of touch on standing balance. Results: Patients had a significantly increased SR compared to control subjects (mean [SD] SR controls = 1.2 [0.2], patients = 1.9 [0.5]; P < 0.01). There was a significant effect of touch, vision, and surface on balance control ("touch" F = 68.1, P < 0.01; "vision" F = 20.1, P < 0.01; "surface" F = 200.8, P < 0.01). Light touch attenuated sway in patients and controls. The effects were greater in controls when their vision was removed, and greater in patients when their somatosensory system was disrupted. Light touch was as effective as UT in attenuating sway. Conclusions: The results of this exploratory study suggest that patients with severe sight impairment show an increased somatosensory contribution to balance control compared to their normally sighted counterparts. Light touch significantly reduces sway amplitude in severely sight impaired adults when standing on the foam surface, that is, when the somatosensory system is perturbed

Virtual clinics in glaucoma care: face-to-face versus remote decision-making

BACKGROUND/AIMS: To examine the agreement in clinical decisions of glaucoma status made in a virtual glaucoma clinic with those made during a face-to-face consultation. METHODS: A trained nurse and technicians entered data prospectively for 204 patients into a proforma. A subsequent face-to-face clinical assessment was completed by either a glaucoma consultant or fellow. Proformas were reviewed remotely by one of two additional glaucoma consultants, and 12 months later, by the clinicians who had undertaken the original clinical examination. The interobserver and intraobserver decision-making agreements of virtual assessment versus standard care were calculated. RESULTS: We identified adverse disagreement between face-to-face and virtual review in 7/204 (3.4%, 95% CI 0.9% to 5.9%) patients, where virtual review failed to predict a need to accelerated follow-up identified in face-to-face review. Misclassification events were rare, occurring in 1.9% (95% CI 0.3% to 3.8%) of assessments. Interobserver κ (95% CI) showed only fair agreement (0.24 (0.04 to 0.43)); this improved to moderate agreement when only consultant decisions were compared against each other (κ=0.41 (0.16 to 0.65)). The intraobserver agreement κ (95% CI) for the consultant was 0.274 (0.073 to 0.476), and that for the fellow was 0.264 (0.031 to 0.497). CONCLUSIONS: The low rate of adverse misclassification, combined with the slowly progressive nature of most glaucoma, and the fact that patients will all be regularly reassessed, suggests that virtual clinics offer a safe, logistically viable option for selected patients with glaucoma

Is there a link between dizziness and vision? A systematic review

YesPurpose: The aim of this study was to systematically review the literature to investigate the link (if any) between vision and dizziness. Methods: Medline, CINAHL, AMED, Web of Science and The Cochrane Library were searched with keywords chosen to find articles which investigated the causes of dizziness and considered vision as a possible trigger. Citation chaining of all included papers was performed in addition to the hand searching of all reference lists. Unpublished literature was identified using www.opengrey.eu. The review considered studies involving adults which link, measure or attempt to improve any aspect of vision in relation to dizziness. Results: Nine thousand six hundred and eighty one possible references were found, and the abstracts were screened independently by two reviewers to determine if they should be included in the study. Thirteen papers were found which investigated whether dizziness was linked to an assessment of vision. Visual impairment measures were crude and typically self-report, or Snellen visual acuity with little or no measurement details. Five studies found an independent link between dizziness and vision, five found a weak association (typically finding a link when univariate analyses were used, but not when multivariate analyses were used), and three found no association. Studies finding a strong link were usually cross-sectional with a large study population whereas those finding a weak association had relatively small numbers of participants. Studies which did not find an association used a broad definition of dizziness that included the term light-headedness, an unreliable Rosenbaum near visual acuity chart or an unusual categorisation of visual acuity. Conclusions: This review suggests that dizziness (although likely not ‘light-headedness’) is linked with poor vision although further studies using more appropriate measures of vision are recommended.Deborah Armstrong was funded by a College of Optometrists Research Scholarship and Emily Charlesworth by a College of Optometrists summer studentship

Collecting multiple data linkage consents in a mixed mode survey: evidence and lessons learnt from next steps

Linking survey responses with administrative data is a promising practice to increase the range of research questions to be explored, at a limited interview burden, both for respondents and interviewers. This paper describes the protocol for asking consent to data linkage on nine different sources in a large-scale nationally representative survey of young adults in England: the Next Steps Age 25 Survey. Evidence from preparatory qualitative research, piloting and from the main stage of the study is presented. This research constitutes a novel contribution to the literature, discussing the practicalities of implementing a data linkage protocol asking consent both retrospectively and prospectively, on multiple domains, and in the context of a mixed-mode survey