Validity of Acute Cardiovascular Outcome Diagnoses Recorded in European Electronic Health Records: A Systematic Review.

Background: Electronic health records are widely used in cardiovascular disease research. We appraised the validity of stroke, acute coronary syndrome and heart failure diagnoses in studies conducted using European electronic health records. Methods: Using a prespecified strategy, we systematically searched seven databases from dates of inception to April 2019. Two reviewers independently completed study selection, followed by partial parallel data extraction and risk of bias assessment. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value estimates were narratively synthesized and heterogeneity between sensitivity and PPV estimates were assessed using I2. Results: We identified 81 studies, of which 20 validated heart failure diagnoses, 31 validated acute coronary syndrome diagnoses with 29 specifically recording estimates for myocardial infarction, and 41 validated stroke diagnoses. Few studies reported specificity or negative predictive value estimates. Sensitivity was ≤66% in all but one heart failure study, ≥80% for 91% of myocardial infarction studies, and ≥70% for 73% of stroke studies. PPV was ≥80% in 74% of heart failure, 88% of myocardial infarction, and 70% of stroke studies. PPV by stroke subtype was variable, at ≥80% for 80% of ischaemic stroke but only 44% of haemorrhagic stroke. There was considerable heterogeneity (I2 >75%) between sensitivity and PPV estimates for all diagnoses. Conclusion: Overall, European electronic health record stroke, acute coronary syndrome and heart failure diagnoses are accurate for use in research, although validity estimates for heart failure and individual stroke subtypes were lower. Where possible, researchers should validate data before use or carefully interpret the results of previous validation studies for their own study purposes

Validity of acute cardiovascular outcome diagnoses in European electronic health records: a systematic review protocol

INTRODUCTION: Cardiovascular diseases (CVDs) are among the leading causes of death globally. Electronic health records (EHRs) provide a rich data source for research on CVD risk factors, treatments and outcomes. Researchers must be confident in the validity of diagnoses in EHRs, particularly when diagnosis definitions and use of EHRs change over time. Our systematic review provides an up-to-date appraisal of the validity of stroke, acute coronary syndrome (ACS) and heart failure (HF) diagnoses in European primary and secondary care EHRs. METHODS AND ANALYSIS: We will systematically review the published and grey literature to identify studies validating diagnoses of stroke, ACS and HF in European EHRs. MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane Library, OpenGrey and EThOS will be searched from the dates of inception to April 2019. A prespecified search strategy of subject headings and free-text terms in the title and abstract will be used. Two reviewers will independently screen titles and abstracts to identify eligible studies, followed by full-text review. We require studies to compare clinical codes with a suitable reference standard. Additionally, at least one validation measure (sensitivity, specificity, positive predictive value or negative predictive value) or raw data, for the calculation of a validation measure, is necessary. We will then extract data from the eligible studies using standardised tables and assess risk of bias in individual studies using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data will be synthesised into a narrative format and heterogeneity assessed. Meta-analysis will be considered when a sufficient number of homogeneous studies are available. The overall quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation tool. ETHICS AND DISSEMINATION: This is a systematic review, so it does not require ethical approval. Our results will be submitted for peer-review publication. PROSPERO REGISTRATION NUMBER: CRD42019123898

Comparative measurements of carbon dioxide fluxes from two nearby towers in a central Amazonian rainforest: the Manaus LBA site

Forests around Manaus have staged the oldest and the longest forest-atmosphere CO2 exchange studies made anywhere in the Amazon. Since July 1999 the exchange of CO2, water, and energy, as well as weather variables, have been measured almost continuously over two forests, 11 km apart, in the Cuieiras reserve near Manaus, Brazil. This paper presents the sites and climatology of the region based upon the new data sets. The landscape consists of plateaus dissected by often waterlogged valleys, and the two sites differ in terms of the relative areas of those two landscape components represented in the tower footprints. The radiation and wind climate was similar to both towers. Generally, both the long-wave and short-wave radiation input was less in the wet than in the dry season. The energy balance closure was imperfect (on average 80%) in both towers, with little variation in energy partitioning between the wet and dry seasons; likely a result of anomalously high rainfall in the 1999 dry season. Fluxes of CO2 also showed little seasonal variation except for a slightly shorter daytime uptake duration and somewhat lower respiratory fluxes in the dry season. The net effect is one of lower daily net ecosystem exchange (NEE) in the dry season. The tower, which has less waterlogged valley areas in its footprint, measured a higher overall CO2 uptake rate. We found that on first sight, NEE is underestimated during calm nights, as was observed in many other tower sites before. However, a closer inspection of the diurnal variation of CO2 storage fluxes and NEE suggests that at least part of the nighttime deficits is recovered from either lateral influx of CO2 from valleys or outgassing of soil storage. Therefore there is a high uncertainty in the magnitude of nocturnal NEE, and consequently preliminary estimates of annual carbon uptake reflecting this range from 1 to 8 T ha-1 y-1, with an even higher upper range for the less waterlogged area. The high uptake rates are clearly unsustainable and call for further investigations into the integral carbon balance of Amazon landscapes

Water and energy fluxes from a woodland savanna (cerrado) in southeast Brazil

Study region: The area of woodland savanna (cerrado) is located in southeast Brazil (21°36′ to 44′ S, 47°34′ to 41′ W). Study focus: The cerrado sensu-stricto savanna evapotranspiration was observed using the eddy-covariance method over three years. New hydrological insights for the region: The first year total rainfall (R = 1664 mm) was 11% above the long-term rainfall (1498 mm) and the total evapotranspiration (ET = 1242 mm) and water equivalent of available energy (Av = 1835 mm) were approximately 4% and 2% greater, respectively, than in the second year when the rainfall total was 5% lower than the long-term average. In the third year despite the total rainfall (1259 mm) being 24% lower than the first year and 16% lower than the average, the totals of ET (1242 mm) and Av (1815 mm) were approximately the same. The small variation in the observed annual ET totals shows that in this cerrado vegetation the deep soil moisture content supports the ET in a dry year and the water available for recharging the soil profile and groundwater (∼R − ET) was dominated by the rainfall amount being significantly greater in the wet year (422 mm) than in the dry year (13 mm)

Ethnic differences in the incidence of clinically diagnosed influenza: an England population-based cohort study 2008-2018 [version 2; peer review: 2 approved]

Background: People of non-White ethnicity have a higher risk of severe outcomes following influenza infection. It is unclear whether this is driven by an increased risk of infection or complications. We therefore aimed to investigate the incidence of clinically diagnosed influenza/influenza-like illness (ILI) by ethnicity in England from 2008-2018. Methods: We used linked primary and secondary healthcare data (from the Clinical Practice Research Datalink [CPRD] GOLD and Aurum databases and Hospital Episodes Statistics Admitted Patient Care [HES APC]). We included patients with recorded ethnicity who were aged 40-64 years and did not have a chronic health condition that would render them eligible for influenza vaccination. ILI infection was identified from diagnostic codes in CPRD and HES APC. We calculated crude annual infection incidence rates by ethnic group. Multivariable Poisson regression models with random effects were used to estimate any ethnic disparities in infection risk. Our main analysis adjusted for age, sex, and influenza year. Results: A total of 3,735,308 adults aged 40-64 years were included in the study; 87.6% White, 5.2% South Asian, 4.2% Black, 1.9% Other, and 1.1% Mixed. We identified 102,316 ILI episodes recorded among 94,623 patients. The rate of ILI was highest in the South Asian (9.6 per 1,000 person-years), Black (8.4 per 1,000 person-years) and Mixed (6.9 per 1,000 person-years) ethnic groups. The ILI rate in the White ethnic group was 5.7 per 1,000 person-years. After adjustment for age sex and influenza year, higher incidence rate ratios (IRR) for ILI were seen for South Asian (1.70, 95% CI 1.66-1.75), Black (1.48, 1.44-1.53) and Mixed (1.22, 1.15-1.30) groups compared to White ethnicity. Conclusions: Our results suggest that influenza infection risk differs between White and non-White groups who are not eligible for routine influenza vaccination

Derivation of the aerodynamic roughness parameters for a Sahelian savannah site using the eddy correlation technique

Vertical exchange of heat, moisture and momentum above the earth's surface depends strongly on the turbulence generated by surface roughness. This roughness is best specified through the roughness length and the zero plane displacement. The ratio of windspeed to friction velocity was measured at four heights using the eddy correlation technique at a fallow savannah site in the Sahel. The change in this ratio with height was used to derive the zero plane displacement and the roughness length of the surface, together with an estimate of the error in each parameter. These were estimated as 0.93 ± 0.35 m and 0.17 ± 0.01 m, respectively. The method appears to be a more robust alternative to wind profile derivation

Risk of acute respiratory infection and acute cardiovascular events following acute respiratory infection among adults with increased cardiovascular risk in England between 2008 and 2018: a retrospective, population-based cohort study

BACKGROUND: Although acute respiratory infections can lead to cardiovascular complications, the effect of underlying cardiovascular risk on the incidence of acute respiratory infections and cardiovascular complications following acute respiratory infection in individuals without established cardiovascular disease is unknown. We aimed to investigate whether cardiovascular risk is associated with increased risk of acute respiratory infection and acute cardiovascular events after acute respiratory infection using 10 years of linked electronic health record (EHR) data in England. METHODS: In this retrospective, population-based cohort study we used EHRs from primary care providers registered on the Clinical Practice Research Datalink (CPRD) GOLD and Aurum databases in England. Eligible individuals were aged 40-64 years, did not have established cardiovascular disease or a chronic health condition that would make them eligible for influenza vaccination, were registered at a general practice contributing to the CPRD, and had linked Hospital Episode Statistics Admitted Patient Care data in England from Sept 1, 2008, to Aug 31, 2018. We classified cardiovascular risk on the basis of diagnosed hypertension and overall predicted cardiovascular risk, estimated by use of the QRISK2 risk-prediction tool (comparing a score of ≥10% [increased risk] with a score of <10% [low risk]). Using multivariable Poisson regression models, we calculated incidence rate ratios (IRRs) for systemic acute respiratory infection. Among individuals who had an acute respiratory infection, we used multivariable Cox regression to calculate hazard ratios (HRs) for the risk of acute cardiovascular events within 1 year of infection. FINDINGS: We identified 6 075 321 individuals aged 40-64 years with data in the CPRD and linked data in the Hospital Episode Statistics Admitted Patient Care database between Sept 1, 2008, and Aug 31, 2018. Of these individuals, 4 212 930 (including 526 480 [12·5%] with hypertension and 607 087 [14·4%] with a QRISK2 score of ≥10%) were included in the assessment of the incidence of acute respiratory infection. After adjusting for confounders (age, sex, ethnicity, socioeconomic status, body-mass index, alcohol consumption, smoking status, and consultation frequency in the hypertension analysis; and alcohol consumption and consultation frequency in the QRISK2 analysis), the incidence of acute respiratory infection was higher in individuals with hypertension than those without (IRR 1·04 [95% CI 1·03-1·05]) and higher in those with a QRISK2 score of 10% or higher than in those with a QRISK2 score of less than 10% (1·39 [1·37-1·40]). Of the 442 408 individuals who had an acute respiratory infection, 4196 (0·9%) had an acute cardiovascular event within 1 year of infection. After adjustment (for age, sex, ethnicity, socioeconomic status, body-mass index, alcohol consumption, and smoking status in the hypertension analysis; and for alcohol consumption in the QRISK2 analysis), hypertension (HR 1·98 [95% CI 1·83-2·15]) and a QRISK2 score of 10% or higher (3·65 [3·42-3·89]) were associated with a substantially increased risk of acute cardiovascular events after acute respiratory infection. INTERPRETATION: People with increased cardiovascular risk but without diagnosed cardiovascular disease, measured by diagnosed hypertension or overall predicted cardiovascular risk, could benefit from influenza and pneumococcal vaccine prioritisation to reduce their risk of both acute respiratory infection and cardiovascular complications following an acute respiratory infection. FUNDING: British Heart Foundation and the Wellcome Trust

Public service markets: their economics, institutional oversight and regulation

Public services in the UK have been transformed over the past 25 years with the introduction of market oriented solutions into their provision. This has been characterised by a shift away from state provision to independent providers, and by the introduction of competition and choice. This shift was partly ideologically motivated and partly driven by budget cutting considerations following the financial crisis. As such it has been lacking a comprehensive economic justification or method of analysis. It is now commonly accepted that the language of economic markets is essential to frame arguments about how effectively public services are achieving their intended outcomes. Using market language and concepts may not always be comfortable for those from a traditional policy-making background. It can nevertheless be very useful when designing investigations into the effectiveness and value for money in the mechanisms of delivery of such services, whenever these services entail a degree of user choice as is currently the case in large parts of health, social care and education (referred to as competition in the market). Our paper wants to provide a conceptual basis on the way of thinking in these terms. We provide a description of the current state and then comment on the desirability of this quasi market approach. Uniquely in the literature, we analyse the expected and desired developments by distinguishing between choice and compulsory merit goods. In choice merit goods markets many users are unable to choose effectively because of the existence of a number of demand side or supply side market failures. Moreover, conflicts may exist between how service users actually make choices, and policy objectives such as universality or equity which may not be achieved simply by ‘leaving it to the market’. The users of compulsory merit goods are typically a minority and unable to internalise the full social benefits of their actions; hence it may be welfare-enhancing for society to coerce them ‘consume’ these services. As choice cannot be an objective, the commissioning (competition for the market) or direct provision by the state of such goods may meet public policy objectives more effectively than the market mechanism alone. Building on these foundations the paper discusses when public service markets are likely to be an effective method of achieving public policy objectives, and when they may not be. Our paper analyses the implications for the institutional and legal framework, funding oversight and regulation of public service markets as a result of their transformation into quasi-markets. The paper concludes with some suggestions for those charged with overseeing public service markets in practice based on this analysis

Sacrificing their Careers for their Families? An Analysis of the Family Pay Penalty in Europe

This paper examines the extent of and the mechanisms behind the penalty to motherhood in six European countries. Each country provides different levels of support for maternal employment allowing us to determine institutional effects on labour market outcome. While mothers tend to earn less than non-mothers, the penalty to motherhood is considerably lower in countries with policy support for working mothers. The paper establishes the United Kingdom and West Germany to have the least policy support for working mothers as well as the largest penalties to motherhood

Synthesis of Mesostructured Copper Sulfide by Cation Exchange and Liquid Crystal Templating

The development of synthetic pathways to yield advanced functional materials is an important aspect of materials science. In particular, the ability to control and manipulate the chemical composition and structure of inorganic nanomaterials is highly desirable. Two synthetic approaches which show great promise for producing the next generation of functional inorganic nanomaterials are (1) templating of supramolecular assemblies and (2) ion exchange within nanostructured inorganic solids to manipulate chemical composition. Templating of supramolecular assemblies of surfactants and amphiphilic polymers has already proven to be a powerful technique in synthesizing various inorganic structures. Namely, numerous examples of mesostructured metal oxides (SiO{sub 2}, TiO{sub 2}, WO{sub 3}, etc.) have been synthesized by templating the liquid crystalline phases of amphiphilic polymers and surfactants (i.e. vesicles, 2D and 3D hexagonal and cubic phases, etc.) with inorganic precursors, resulting in the formation of highly ordered inorganic-organic hybrid materials. Although the templating of supramolecular assemblies has been successful in generating highly ordered mesostructured metal oxides, there are only a few examples of non-oxidic mesostructured inorganic materials. The recent developments of ion exchange within nanoparticles offer a promising approach to generating novel nanostructured inorganic materials with unique chemical compositions. Konenkamp et al. and Alivisatos et al. have successfully utilized the ion exchange methods to fully transform the chemical composition of simple nanostructured inorganic materials while retaining their shapes. Although the exact mechanism by which the ions exchange while retaining the overall structure is still unclear, this approach combined with templating of supramolecular assemblies can provide a potent technique for obtaining highly ordered inorganic materials with unique structures and chemical compositions. Herein, we describe for the first time, the successful synthesis of highly ordered, mesostructured Cu{sub x}S, by combining the templating of the supramolecular assemblies of non-ionic amphiphilic polymer method with the cation exchange method to transform mesostructured cadmium sulfide (CdS) into mesostructured copper sulfides (CuS, Cu{sub 2}S)