Recorded vignettes: a novel method for investigating documentation in the Electronic Healthcare Record (EHR)

Background: 360 million consultations documented annually in England1 Accurate descriptors required for secondary data functions: Computerised decision support; Financial reimbursement; Audit; Disease prevalence monitoring and research Coding is not explicitly taught within the GP curriculum How do you research how clinicians document? Previous studies: use real patients2/actors3 interacting with clinician studied; Lack standardisation; Expensive. Why Allergy? Growing clinical problem; 2014 NICE guidelines4: Poor clinical documentation is a major issue in allergy; EHR can’t distinguish between intolerance and allergy; Incorrect labelling of patients; Adverse impact on patient care? Little known about coding practices in non-incentivised condition such as allergy. Method: A novel method developed to standardize research of EHR use. Filmed 6 short vignettes (21-50 secs) Monologue of common allergic presentations as if in consultation with a doctor. Digital photographs were included to replicate rashes. Electronic distribution of study files Documented vignettes in their own EHR Returned screen-prints to the researcher for analysis - Codes, free text and EHR functions Questionnaire - Exploring decision-making and validation of method Initially piloted on 1 GP and 2 trainees leading to refinements. Results 7 GPs and 15 GP trainees were recruited All successfully completed Data was returned from 4 different EHRs SystmOne (6), EmisLV (2), EmisWeb (6) and Vision (8) Screen prints effectively captured data with minor technical difficulties reported by 2 participants The study took 1 - 2 hours to complete: longer than expected from the pilot study

Exploring practical approaches to maximising data quality in electronic healthcare records in the primary care setting and associated benefits

Exploiting the information contained within electronic healthcare records (EHR) data will be key to addressing major challenges to public health both nationally and globally, ultimately offering a means of maximising efficiency and equality in care. There are, however, significant challenges in using EHRs effectively and particularly in ensuring the quality of data recorded. Incorrect or missing data could render records as useless or indeed misleading such that conclusions drawn from the data could have a negative impact. Amongst other difficulties, recording data can be time consuming to the extent of conflicting with the GP’s primary focus of patient consultation in an already time-constrained environment. Understanding the requirements of and the demands upon GPs must be central to addressing the issue of data quality (DQ) within EHRs. As part of on-going work into DQ at the Clinical Practice Research Datalink (CPRD) and in collaboration with the University of Sussex (UoS), a workshop session was held at the SAPC (Society for Academic Primary Care) conference in 2014 with the aim of exploring issues of DQ in primary care EHRs from the perspective of different users of GP data and with particular focus on how and why data is recorded in the first instance. The intended outcome was a furthered understanding of both the challenges and the direct benefits to GPs of ensuring high quality data with a view to establishing a workable approach to recording data and maximising benefits to all users of EHRs

Body Composition Changes among Medical Students Following Matriculation

Purpose: Participation in medical education has been associated with an increased propensity for poor health in other studies. Information regarding the body composition and physical activity patterns of medical students and how they are affected by the rigors of medical school is lacking in the current literature. We sought to assess changes in body composition and physical activity levels of medical students during the first three years of the curriculum. Methods: Using anthropometric measurements, bioelectrical impedance analysis and a validated physical activity questionnaire, we measured 44 medical students upon matriculation, at the end of the preclinical curriculum (16 months after matriculation) and at the completion of the third year of clinical rotations (40 months after matriculation). Results: The 44 subjects did not exhibit significant changes in weight, body mass index (BMI), or any measures of the various measures of body composition. However, for the 24 female subjects a negative correlation was found between the first energy expenditure measurement and the percent total body fat (p= 0.02, r= -0.49). There was also a negative relationship in the females between the second energy expenditure measurement and the percent total body fat (p= 0.00, r= -0.63). Finally, lower percent TBF was correlated with higher energy expenditure at the third measurement (p= 0.40, r = -0.43). For male subjects, there was no significant correlation between weight, BMI or percent TBF and energy expenditure. Conclusion: Our results indicate that medical school may not necessarily be as detrimental to the health and activity profiles of medical students as is popularly believed. These findings are contradictory to most studies of medical student health and address the need for further prospective studies of health in this population. Lower percent TBF in female subjects was consistently correlated with higher self-reported energy expenditure. This finding was expected, as sedentary lifestyles are associated with overweight and obesity

Quality of recording of diabetes in the UK: how does the GP’s method of coding clinical data affect incidence estimates? Cross-sectional study using the CPRD database

Objective: To assess the effect of coding quality on estimates of the incidence of diabetes in the UK between 1995 and 2014. Design: A cross-sectional analysis examining diabetes coding from 1995 to 2014 and how the choice of codes (diagnosis codes vs codes which suggest diagnosis) and quality of coding affect estimated incidence. Setting: Routine primary care data from 684 practices contributing to the UK Clinical Practice Research Datalink (data contributed from Vision (INPS) practices). Main outcome measure: Incidence rates of diabetes and how they are affected by (1) GP coding and (2) excluding ‘poor’ quality practices with at least 10% incident patients inaccurately coded between 2004 and 2014. Results: Incidence rates and accuracy of coding varied widely between practices and the trends differed according to selected category of code. If diagnosis codes were used, the incidence of type 2 increased sharply until 2004 (when the UK Quality Outcomes Framework was introduced), and then flattened off, until 2009, after which they decreased. If non-diagnosis codes were included, the numbers continued to increase until 2012. Although coding quality improved over time, 15% of the 666 practices that contributed data between 2004 and 2014 were labelled ‘poor’ quality. When these practices were dropped from the analyses, the downward trend in the incidence of type 2 after 2009 became less marked and incidence rates were higher. Conclusions: In contrast to some previous reports, diabetes incidence (based on diagnostic codes) appears not to have increased since 2004 in the UK. Choice of codes can make a significant difference to incidence estimates, as can quality of recording. Codes and data quality should be checked when assessing incidence rates using GP data

Filmed monologue vignettes: a novel method for investigating how clinicians document consultations in electronic health records

Introduction and Objectives The accuracy of conclusions based on Electronic Healthcare Record (EHR) research is highly dependent on the correct selection of descriptors (codes) by users. We aimed to evaluate the feasibility and acceptability of filmed vignette monologues as a resource-light method of assessing and comparing how different EHR users record the same clinical scenario. Methods Six short monologues of actors portraying patients presenting allergic conditions to their General Practitioners were filmed head-on then electronically distributed for the study; no researcher was present during data collection. The method was assessed by participant uptake, reported ease of completion by participants, compliance with instructions, the receipt of interpretable data by researchers, and participant perceptions of vignette quality, realism and information content. Results 22 participants completed the study, reporting only minor difficulties. 132 screen prints were returned electronically, enabling analysis of codes, free text and EHR features. Participants assigned a quality rating of 7.7/10 (range 2-10) to the vignettes and rated the extent to which vignettes reflected real-life (86-100%). Between 1 and 2 hours were required to complete the task. Full compliance with instructions varied between participants but was largely successful. Conclusions Filmed monologues are a reproducible, standardized method which require few resources, yet allow clear assessment of clinicians’ and EHRs systems’ impact on documentation. The novel nature of this method necessitates clear instructions so participants can fully complete the study without face to face researcher oversight

Evaluating the Potential for Harmonized Prediction and Comparison of Disposal?Stage Greenhouse Gas Emissions for Biomaterial Products

The carbon footprint (CF) of biofuels and biomaterials is a barrier to their acceptance, yet the greenhouse gas emissions associated with disposing of biomaterials are frequently omitted from analyses. This article investigates whether harmonization is appropriate for calculating the importance of biomaterials’ disposal. This research shows that disposal stages could double a biomaterial's CF, or reduce it to the point that it could claim to be zero carbon. Incineration with combined heat and power coupled with on-site energy production in the biorefinery are identified as prerequisites to being zero carbon. The article assesses the current UK waste infrastructure's ability to support a low-carbon bio-based future economy, and finds that presently it only achieves marginal net reductions when compared to landfill and so cannot be said to support low-carbon biomaterials, though the article challenges the polluter pays principle where low-carbon disposal infrastructure are not available. Reuse and recycling are shown to have the potential to offset all the emissions caused by landfill of biomaterials. However, the savings are not so great as to offset the biomaterial's upstream emissions. The study explores the ability to overcome the barriers to incorporating disposal into life cycle assessment while identifying limitations of using harmonization as an assessment method. Specifically, data availability and industry consensus are flagged as major barriers. The study also uses sensitivity analysis to investigate the influence of methodological choices, such as allowing additional reuse and recycling stages, classifying biomaterials into different types, and choosing between opposing allocation methods

A novel strategy for the identification of antigens that are recognised by bovine MHC class I restricted cytotoxic T cells in a protozoan infection using reverse vaccinology

BACKGROUND: Immunity against the bovine protozoan parasite Theileria parva has previously been shown to be mediated through lysis of parasite-infected cells by MHC class I restricted CD8(+ )cytotoxic T lymphocytes. It is hypothesized that identification of CTL target schizont antigens will aid the development of a sub-unit vaccine. We exploited the availability of the complete genome sequence data and bioinformatics tools to identify genes encoding secreted or membrane anchored proteins that may be processed and presented by the MHC class I molecules of infected cells to CTL. RESULTS: Of the 986 predicted open reading frames (ORFs) encoded by chromosome 1 of the T. parva genome, 55 were selected based on the presence of a signal peptide and/or a transmembrane helix domain. Thirty six selected ORFs were successfully cloned into a eukaryotic expression vector, transiently transfected into immortalized bovine skin fibroblasts and screened in vitro using T. parva-specific CTL. Recognition of gene products by CTL was assessed using an IFN-γ ELISpot assay. A 525 base pair ORF encoding a 174 amino acid protein, designated Tp2, was identified by T. parva-specific CTL from 4 animals. These CTL recognized and lysed Tp2 transfected skin fibroblasts and recognized 4 distinct epitopes. Significantly, Tp2 specific CD8(+ )T cell responses were observed during the protective immune response against sporozoite challenge. CONCLUSION: The identification of an antigen containing multiple CTL epitopes and its apparent immunodominance during a protective anti-parasite response makes Tp2 an attractive candidate for evaluation of its vaccine potential

Prediction of mosquito species and population age structure using mid-infrared spectroscopy and supervised machine learning

Despite the global efforts made in the fight against malaria, the disease is resurging. One of the main causes is the resistance that Anopheles mosquitoes, vectors of the disease, have developed to insecticides. Anopheles must survive for at least 10 days to possibly transmit malaria. Therefore, to evaluate and improve malaria vector control interventions, it is imperative to monitor and accurately estimate the age distribution of mosquito populations as well as their population sizes. Here, we demonstrate a machine-learning based approach that uses mid-infrared spectra of mosquitoes to characterise simultaneously both age and species identity of females of the African malaria vector species Anopheles gambiae and An. arabiensis. mid-infrared spectroscopy-based prediction of mosquito age structures was statistically indistinguishable from true modelled distributions. The accuracy of classifying mosquitoes by species was 82.6%. The method has a negligible cost per mosquito, does not require highly trained personnel, is rapid, and so can be easily applied in both laboratory and field settings. Our results indicate this method is a promising alternative to current mosquito species and age-grading approaches, with further improvements to accuracy and expansion for use with other mosquito vectors possible through collection of larger mid-infrared spectroscopy data sets

Comparative Geno-Plasticity Analysis of Mycoplasma bovis HB0801 (Chinese Isolate)

Mycoplasma bovis pneumonia in cattle has been epidemic in China since 2008. To investigate M. bovis pathogenesis, we completed genome sequencing of strain HB0801 isolated from a lesioned bovine lung from Hubei, China. The genomic plasticity was determined by comparing HB0801 with M. bovis strain ATCC® 25523™/PG45 from cow mastitis milk, Chinese strain Hubei-1 from lesioned lung tissue, and 16 other Mycoplasmas species. Compared to PG45, the genome size of HB0801 was reduced by 11.7 kb. Furthermore, a large chromosome inversion (580 kb) was confirmed in all Chinese isolates including HB0801, HB1007, a strain from cow mastitis milk, and Hubei-1. In addition, the variable surface lipoproteins (vsp) gene cluster existed in HB0801, but contained less than half of the genes, and had poor identity to that in PG45, but they had conserved structures. Further inter-strain comparisons revealed other mechanisms of gene acquisition and loss in HB0801 that primarily involved insertion sequence (IS) elements, integrative conjugative element, restriction and modification systems, and some lipoproteins and transmembrane proteins. Subsequently, PG45 and HB0801 virulence in cattle was compared. Results indicated that both strains were pathogenic to cattle. The scores of gross pathological assessment for the control group, and the PG45- and HB0801-infected groups were 3, 13 and 9, respectively. Meanwhile the scores of lung lesion for these three groups were 36, 70, and 69, respectively. In addition, immunohistochemistry detection demonstrated that both strains were similarly distributed in lungs and lymph nodes. Although PG45 showed slightly higher virulence in calves than HB0801, there was no statistical difference between the strains (P>0.05). Compared to Hubei-1, a total of 122 SNP loci were disclosed in HB0801. In conclusion, although genomic plasticity was thought to be an evolutionary advantage, it did not apparently affect virulence of M. bovis strains in cattle