Developing a conformance methodology for clinically-defined medical record headings:a preliminary report.

Background: The Professional Records Standards Body for health and social care (PRSB) was formed in 2013 to develop and assure professional standards for the content and structure of patient records across all care disciplines in the UK. Although the PRSB work is aimed at Electronic Health Record (EHR) adoption and interoperability to support continuity of care, the current technical guidance is limited and ambiguous. Objectives: This project was initiated as a proof-ofconcept to demonstrate whether, and if so, how, conformance methods can be developed based on the professional standards. Methods: An expert group was convened, comprising clinical and technical representatives. A constrained data set was defined for an outpatient letter, using the subset of outpatient headings that are also present in the ep-SOS patient summary. A mind map was produced for the main sections and sub-sections. An openEHR archetype model was produced as the basis for creating HL7 and IHE implementation artefacts. Results: Several issues about data definition and representation were identified when attempting to map the outpatient headings to the epSOS patient summary, partly due to the difference between process and static viewpoints. Mind maps have been a simple and helpful way to visualize the logical information model and expose and resolve disagreements about which headings are purely for human navigation and which, if any, have intrinsic meaning. Conclusions: Conformance testing is feasible but nontrivial. In contrast to traditional standards-development timescales, PRSB needs an agile standards development process with EHR vendor and integrator collaboration to ensure implementability and widespread adoption. This will require significant clinical and technical resources

Using non-nutritive sucking to support feeding development for premature infants: A commentary on approaches and current practice

Non-nutritive sucking is often used with premature infants by either using a pacifier or an expressed breast nipple to support the introduction and development of early oral feeding. The pattern of non-nutritive sucking is distinct in that it involves two sucks per second in contrast to nutritive sucking which is one suck per second. Although some literature has identified that non-nutritive sucking has some benefit for the premature infant’s feeding development, it is not entirely clear why such an approach is helpful as neurologically, activation of non-nutritive and nutritive skills are different. A summary is presented of the main approaches that use non-nutritive sucking with reference to the literature. This paper also considers other factors and beneficial approaches to managing the introduction of infant feeding. These are: the infant’s toleration of enteral feeds pre oral trials, overall development and gestational age when introducing oral experiences, developing swallowing skills before sucking, physiological stability, health status, as well as the development and interpretation of infant oral readiness signs and early communication

Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers

BACKGROUND: Accurate recording of problems and diagnoses in health records is key to safe and effective patient care, yet it is often done poorly. Electronic health record systems vary in their functionality and ease of use, and are not optimally designed for easy recording and sharing of clinical information. There is a lack of professional consensus and guidance on how problems and diagnoses should be recorded. METHODS: The Professional Record Standards Body commissioned work led by the Royal College of Physicians Health Informatics Unit to carry out a literature review, draft guidance, carry out an online consultation and round table discussion, and produce a report including recommendations for systems. A patient workshop was held to explore patient preferences for mechanisms for sharing diagnosis information between primary and secondary care. RESULTS: Consensus was reached among medical specialties on key elements of diagnosis recording, and draft guidance was produced ready for piloting in a variety of care settings. Patients were keen for better ways for diagnosis information to be shared. DISCUSSION: Improving the recording of diagnoses and problems will require a major effort of which the new guidance is only a part. The guidance needs to be embedded in training, and clinical systems need to have improved, standardised functionality. Front-line clinicians, specialist societies, clinical informaticians and patients need to be engaged in developing information models for diagnoses to support care and research, accessible via user-friendly interfaces

Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers.

Funder: Professional Record Standards BodyFunder: Royal College of Physicians; FundRef: http://dx.doi.org/10.13039/501100000395BACKGROUND: Accurate recording of problems and diagnoses in health records is key to safe and effective patient care, yet it is often done poorly. Electronic health record systems vary in their functionality and ease of use, and are not optimally designed for easy recording and sharing of clinical information. There is a lack of professional consensus and guidance on how problems and diagnoses should be recorded. METHODS: The Professional Record Standards Body commissioned work led by the Royal College of Physicians Health Informatics Unit to carry out a literature review, draft guidance, carry out an online consultation and round table discussion, and produce a report including recommendations for systems. A patient workshop was held to explore patient preferences for mechanisms for sharing diagnosis information between primary and secondary care. RESULTS: Consensus was reached among medical specialties on key elements of diagnosis recording, and draft guidance was produced ready for piloting in a variety of care settings. Patients were keen for better ways for diagnosis information to be shared. DISCUSSION: Improving the recording of diagnoses and problems will require a major effort of which the new guidance is only a part. The guidance needs to be embedded in training, and clinical systems need to have improved, standardised functionality. Front-line clinicians, specialist societies, clinical informaticians and patients need to be engaged in developing information models for diagnoses to support care and research, accessible via user-friendly interfaces

Information standards for recording alcohol use in electronic health records::Findings from a national consultation

Abstract Background Alcohol misuse is an important cause of premature disability and death. While clinicians are recommended to ask patients about alcohol use and provide brief interventions and specialist referral, this is poorly implemented in routine practice. We undertook a national consultation to ascertain the appropriateness of proposed standards for recording information about alcohol use in electronic health records (EHRs) in the UK and to identify potential barriers and facilitators to their implementation in practice. Methods A wide range of stakeholders in the UK were consulted about the appropriateness of proposed information standards for recording alcohol use in EHRs via a multi-disciplinary stakeholder workshop and online survey. Responses to the survey were thematically analysed using the Consolidated Framework for Implementation Research. Results Thirty-one stakeholders participated in the workshop and 100 in the online survey. This included patients and carers, healthcare professionals, researchers, public health specialists, informaticians, and clinical information system suppliers. There was broad consensus that the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-Consumption (AUDIT-C) questionnaires were appropriate standards for recording alcohol use in EHRs but that the standards should also address interventions for alcohol misuse. Stakeholders reported a number of factors that might influence implementation of the standards, including having clear care pathways and an implementation guide, sharing information about alcohol use between health service providers, adequately resourcing the implementation process, integrating alcohol screening with existing clinical pathways, having good clinical information systems and IT infrastructure, providing financial incentives, having sufficient training for healthcare workers, and clinical leadership and engagement. Implementation of the standards would need to ensure patients are not stigmatised and that patient confidentiality is robustly maintained. Conclusions A wide range of stakeholders agreed that use of AUDIT-C and AUDIT are appropriate standards for recording alcohol use in EHRs in addition to recording interventions for alcohol misuse. The findings of this consultation will be used to develop an appropriate information model and implementation guide. Further research is needed to pilot the standards in primary and secondary care

Oldest known pantherine skull and evolution of the tiger

The tiger is one of the most iconic extant animals, and its origin and evolution have been intensely debated. Fossils attributable to extant pantherine species-lineages are less than 2 MYA and the earliest tiger fossils are from the Calabrian, Lower Pleistocene. Molecular studies predict a much younger age for the divergence of modern tiger subspecies at <100 KYA, although their cranial morphology is readily distinguishable, indicating that early Pleistocene tigers would likely have differed markedly anatomically from extant tigers. Such inferences are hampered by the fact that well-known fossil tiger material is middle to late Pleistocene in age. Here we describe a new species of pantherine cat from Longdan, Gansu Province, China, Panthera zdanskyi sp. nov. With an estimated age of 2.55–2.16 MYA it represents the oldest complete skull of a pantherine cat hitherto found. Although smaller, it appears morphologically to be surprisingly similar to modern tigers considering its age. Morphological, morphometric, and cladistic analyses are congruent in confirming its very close affinity to the tiger, and it may be regarded as the most primitive species of the tiger lineage, demonstrating the first unequivocal presence of a modern pantherine species-lineage in the basal stage of the Pleistocene (Gelasian; traditionally considered to be Late Pliocene). This find supports a north-central Chinese origin of the tiger lineage, and demonstrates that various parts of the cranium, mandible, and dentition evolved at different rates. An increase in size and a reduction in the relative size of parts of the dentition appear to have been prominent features of tiger evolution, whereas the distinctive cranial morphology of modern tigers was established very early in their evolutionary history. The evolutionary trend of increasing size in the tiger lineage is likely coupled to the evolution of its primary prey species

Engineered biosynthesis of bacteriochlorophyll b in Rhodobacter sphaeroides.

Bacteriochlorophyll b has the most red-shifted absorbance maximum of all naturally occurring photopigments. It has a characteristic ethylidene group at the C8 position in place of the more common ethyl group, the product of a C8-vinyl reductase, which is carried by the majority of chlorophylls and bacteriochlorophylls used in photosynthesis. The subsequent and first step exclusive to bacteriochlorophyll biosynthesis, the reduction of the C7=C8 bond, is catalyzed by chlorophyllide oxidoreductase. It has been demonstrated that the enzyme from bacteriochlorophyll a-utilizing bacteria can catalyze the formation of compounds carrying an ethyl group at C8 from both ethyl- and vinyl-carrying substrates, indicating a surprising additional C8-vinyl reductase function, while the enzyme from organisms producing BChl b could only catalyze C7=C8 reduction with a vinyl substrate, but this product carried an ethylidene group at the C8 position. We have replaced the native chlorophyllide oxidoreductase-encoding genes of Rhodobacter sphaeroides with those from Blastochloris viridis, but the switch from bacteriochlorophyll a to b biosynthesis is only detected when the native conventional C8-vinyl reductase is absent. We propose a non-enzymatic mechanism for ethylidene group formation based on the absence of cellular C8-vinyl reductase activity

Nanomechanics and Sodium Permeability of Endothelial Surface Layer Modulated by Hawthorn Extract WS 1442

The endothelial glycocalyx (eGC) plays a pivotal role in the physiology of the vasculature. By binding plasma proteins, the eGC forms the endothelial surface layer (ESL) which acts as an interface between bloodstream and endothelial cell surface. The functions of the eGC include mechanosensing of blood flow induced shear stress and thus flow dependent vasodilation. There are indications that levels of plasma sodium concentrations in the upper range of normal and beyond impair flow dependent regulation of blood pressure and may therefore increase the risk for hypertension. Substances, therefore, that prevent sodium induced endothelial dysfunction may be attractive for the treatment of cardiovascular disease. By means of combined atomic force - epifluorescence microscopy we studied the impact of the hawthorn (Crataegus spp.) extract WS 1442, a herbal therapeutic with unknown mechanism of action, on the mechanics of the ESL of ex vivo murine aortae. Furthermore, we measured the impact of WS 1442 on the sodium permeability of endothelial EA.hy 926 cell monolayer. The data show that (i) the ESL contributes by about 11% to the total endothelial barrier resistance for sodium and (ii) WS 1442 strengthens the ESL resistance for sodium up to about 45%. This mechanism may explain some of the vasoprotective actions of this herbal therapeutic