Data quality predicts care quality: findings from a national clinical audit

Background: Missing clinical outcome data are a common occurrence in longitudinal studies. Data quality in clinical audit is a particular cause for concern. The relationship between departmental levels of missing clinical outcome data and care quality is not known. We hypothesise that completeness of key outcome data in a national audit predicts departmental performance. Methods: The National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis (NCAREIA) collected data on care of patients with suspected rheumatoid arthritis (RA) from early 2014 to late 2015. This observational cohort study collected data on patient demographics, departmental variables, service quality measures including time to treatment, and the key RA clinical outcome measure, disease activity at baseline, and 3 months follow-up. A mixed effects model was conducted to identify departments with high/low proportions of missing baseline disease activity data with the results plotted on a caterpillar graph. A mixed effects model was conducted to assess if missing baseline disease activity predicted prompt treatment. Results: Six thousand two hundred five patients with complete treatment time data and a diagnosis of RA were recruited from 136 departments. 34.3% had missing disease activity at baseline. Mixed effects modelling identified 13 departments with high levels of missing disease activity, with a cluster observed in the Northwest of England. Missing baseline disease activity was associated with not commencing treatment promptly in an adjusted mix effects model, odds ratio 0.50 (95% CI 0.41 to 0.61, p < 0.0001). Conclusions: We have shown that poor engagement in a national audit program correlates with the quality of care provided. Our findings support the use of data completeness as an additional service quality indicator

Electronic screening for mental illness in patients with psoriasis

In this cross sectional study from a large UK centre, screening for mental illness in individuals with psoriasis has demonstrated a high burden of depression and anxiety. 85% of the cohort report that their psoriasis had affected their quality of life. Quality of life scores correlate with depression scores, emphasing the importance of managing individual's mental health alongside their psoriasis to improve overall quality of life

The nitrogen footprint of Ukraine: why personal consumption matters

Unintended reactive nitrogen (N) losses from agriculture, energy and transportation pose significant environmental hazards, including eutrophication, acidification, water and air pollution, biodiversity loss, human health risks and climate change. The concept of a Nitrogen Footprint (NF) emerges as a pivotal metric, reflecting potential N losses in the entire production-consumption chain of goods and services used by an individual within a defined timeframe. In a pioneering assessment of per capita NF in Ukraine, key factors, such as the food production chain, consumption patterns, connection to wastewater treatment (WWT) system and the efficacy of WWT facilities, were identified as critical components. Addressing specific challenges, such as data availability, soil N depletion and manure waste, was found to be particularly complex. The apparent high nitrogen use efficiency (NUE) in Ukrainian cropping systems was highlighted to be actually reflected in the elevated N mineralization rate in Ukrainian soils characterized by high organic matter content. The individual Ukraine NF (22.1 kg N cap-1 yr-1 as of 2017) was found to be much lower than that of the US and Australia being comparable to Western European countries. Even so, significant opportunities for reduction remain through a wide range of options towards healthier and more sustainable dietary choices. Potential reductions, ranging from 22% to 69%, were shown for omnivore, reduced red meat, no red meat, half meat products, vegetarian and vegan diets. In the absence of proper manure management in Ukraine, even greater reductions of an ‘actual’ NF can be achieved if wasted N manure is considered. The war's impact is assumed to result in a slight increase or no changes in individual food consumption NFs and an increase in food production NFs for local products, while reductions in individual transport and energy NFs were likely across Ukraine. Nonetheless, refugees massively displaced to less affected regions overload a largely outdated civilian infrastructure, leading to higher N losses. Looking ahead, sustained support, capital investments, legislative enhancements and regulatory frameworks, especially upon post-war renovation of Ukraine, are imperative for reducing the individual NF. This involves enhancing nitrogen use efficiency in agriculture, establishing efficient manure management, upgrading WWT facilities, promoting renewable energy adoption, bolstering requisite infrastructure and raising public awareness on environmental sustainability

Intentional versus unintentional nitrogen use in the United States : trends, efficiency and implications

© The Author(s), 2012. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Biogeochemistry 114 (2013): 11-23, doi:10.1007/s10533-012-9801-5.Human actions have both intentionally and unintentionally altered the global economy of nitrogen (N), with both positive and negative consequences for human health and welfare, the environment and climate change. Here we examine long-term trends in reactive N (Nr) creation and efficiencies of Nr use within the continental US. We estimate that human actions in the US have increased Nr inputs by at least ~5 times compared to pre-industrial conditions. Whereas N2 fixation as a by-product of fossil fuel combustion accounted for ~1/4 of Nr inputs from the 1970s to 2000 (or ~7 Tg N year−1), this value has dropped substantially since then (to <5 Tg N year−1), owing to Clean Air Act amendments. As of 2007, national N use efficiency (NUE) of all combined N inputs was equal to ~40 %. This value increases to 55 % when considering intentional N inputs alone, with food, industrial goods, fuel and fiber production accounting for the largest Nr sinks, respectively. We estimate that 66 % of the N lost during the production of goods and services enters the air (as NO x , NH3, N2O and N2), with the remaining 34 % lost to various waterways. These Nr losses contribute to smog formation, acid rain, eutrophication, biodiversity declines and climate change. Hence we argue that an improved national NUE would: (i) benefit the US economy on the production side; (ii) reduce social damage costs; and (iii) help avoid some major climate change risks in the future.This work resulted from a workshop supported by NSF Research Coordination Network Awards DEB-0443439 and DEB-1049744 and by the David and Lucille Packard Foundation

Anti-TNF therapy is associated with an increased risk of serious infections in patients with rheumatoid arthritis especially in the first 6 months of treatment: updated results from the British Society for Rheumatology Biologics Register with special emphasis on risks in the elderly

Objectives. To evaluate the risk of serious infections (SIs) in patients with RA treated with anti-TNF therapy with emphasis on the risk across different ages

Physiological effects of major genes affecting ovulation rate in sheep

Genetic mutations with major effects on ovulation rate in sheep were recently identified in two genes of the transforming growth factor (TGFβ) superfamily and a TGFβ receptor, namely bone morphogenetic protein 15 (BMP15), otherwise known as the growth differentiation factor 9b (GDF9b), GDF9 and activin-like kinase 6 (ALK6) otherwise known as the BMP receptor type IB (BMPRIB). Animals homozygous for the BMP15 or GDF9 mutations are anovulatory whereas animals heterozygous for BMP15 or GDF9 or heterozygous or homozygous for ALK6 have higher than normal ovulation rates. Immunisation of ewes against BMP15 or GDF9 shows that both are essential for normal follicular development and control of ovulation rate. Common features of fertile animals with the BMP15, ALK6 (and possibly GDF9) mutations are changes in oocyte development during early preantral follicular growth, earlier maturation of granulosa cells and ovulation of mature follicles at smaller diameters. In summary, these findings have led to a new paradigm in reproductive biology, namely that the oocyte plays a key role in regulating the ovulation rate

Dynamical Stability of Six-Dimensional Warped Brane-Worlds

We study a generalization of the Randall-Sundrum mechanism for generating the weak/Planck hierarchy, which uses two rather than one warped extra dimension, and which requires no negative tension branes. A 4-brane with one exponentially large compact dimension plays the role of the Planck brane. We investigate the dynamical stability with respect to graviton, graviphoton and radion modes. The radion is shown to have a tachyonic instability for certain models of the 4-brane stress-energy, while it is stable in others, and massless in a special case. If stable, its mass is in the milli-eV range, for parameters of the model which solve the hierarchy problem. The radion is shown to couple to matter with gravitational strength, so that it is potentially detectable by submillimeter-range gravity experiments. The radion mass can be increased using a bulk scalar field in the manner of Goldberger and Wise, but only to order MeV, due to the effect of the large extra dimension. The model predicts a natural scale of 10^{13} GeV on the 4-brane, making it a natural setting for inflation from the ultraviolet brane.Comment: 28 pages, 7 figure