Protocol: Which variables are useful for phenotyping dementia in primary care records? A meta-analysis

Dementia is usually identified in primary care by general practitioners (GPs) and most identified patients are referred on to memory assessment clinics for formal diagnosis. However, epidemiological studies suggest only 50% of dementia cases are recorded in general practice. The UK government and the NHS have made increasing diagnosis rates a strategic priority. A range of indicators in the primary care record are likely to be predictive of patients at high risk of dementia and could be combined in a predictive model to help increase diagnosis rates. As part of the Wellcome Trust funded ASTRODEM study, we aim to conduct a systematic review and meta-analysis to identify conditions and medications previously found to be associated with dementia in primary care records

The Lobby in transition: what the 2009 MPs’ expenses scandal revealed about the changing relationship between politicians and the Westminster Lobby?

The 2009 MPs' expenses scandal was one of the most significant political stories of modern times. It raised questions, not just about the ethics and behaviour of MPs but also about the relationship between politicians at Westminster and the political correspondents who follow them on a daily basis, known as ‘the lobby’. For the significance of this scandal, in media terms, was that the story was not broken by members of the lobby but came from outside the traditional Westminster news gathering process. This paper examines why this was the case and it compares the lobby today with that which was described and analysed by Jeremy Tunstall and Colin Seymour-Ure in their respective studies more than 40 years ago. The article concludes that the lobby missed the story partly because of the nature of the lobby itself and partly as a result of a number of specific changes which have taken place in the media and the political systems over the past 40 years

Personalized diagnosis in suspected myocardial infarction

Background: In suspected myocardial infarction (MI), guidelines recommend using high-sensitivity cardiac troponin (hscTn)- based approaches. These require fixed assay-specific thresholds and timepoints, without directly integrating clinical information. Using machine-learning techniques including hs-cTn and clinical routine variables, we aimed to build a digital tool to directly estimate the individual probability of MI, allowing for numerous hs-cTn assays. Methods: In 2,575 patients presenting to the emergency department with suspected MI, two ensembles of machine-learning models using single or serial concentrations of six different hs-cTn assays were derived to estimate the individual MI probability ( ARTEMIS model). Discriminative performance of the models was assessed using area under the receiver operating characteristic curve (AUC) and logLoss. Model performance was validated in an external cohort with 1688 patients and tested for global generalizability in 13 international cohorts with 23,411 patients. Results: Eleven routinely available variables including age, sex, cardiovascular risk factors, electrocardiography, and hs-cTn were included in the ARTEMIS models. In the validation and generalization cohorts, excellent discriminative performance was confirmed, superior to hs-cTn only. For the serial hs-cTn measurement model, AUC ranged from 0.92 to 0.98. Good calibration was observed. Using a single hs-cTn measurement, the ARTEMIS model allowed direct rule-out of MI with very high and similar safety but up to tripled efficiency compared to the guideline- recommended strategy. Conclusion We developed and validated diagnostic models to accurately estimate the individual probability of MI, which allow for variable hs-cTn use and flexible timing of resampling. Their digital application may provide rapid, safe and efficient personalized patient care

Predicting dementia from primary care records: a systematic review and meta-analysis

Introduction Possible dementia is usually identified in primary care by general practitioners (GPs) who refer to specialists for diagnosis. Only two-thirds of dementia cases are currently recorded in primary care, so increasing the proportion of cases diagnosed is a strategic priority for the UK and internationally. Clinical entities in the primary care record may indicate risk of developing dementia, and could be combined in a predictive model to help find patients who are missing a diagnosis. We conducted a meta-analysis to identify clinical entities with potential for use in such a predictive model for dementia in primary care. Methods and Findings We conducted a systematic search in PubMed, Web of Science and primary care database bibliographies. We included cohort or case-control studies which used routinely collected primary care data, to measure the association between any clinical entity and dementia. Meta-analyses were performed to pool odds ratios. A sensitivity analysis assessed the impact of non-independence of cases between studies. From a sift of 3836 papers, 20 studies, all European, were eligible for inclusion, comprising >1 million patients. 75 clinical entities were assessed as risk factors for all cause dementia, Alzheimer’s (AD) and Vascular dementia (VaD). Data included were unexpectedly heterogeneous, and assumptions were made about definitions of clinical entities and timing as these were not all well described. Meta-analysis showed that neuropsychiatric symptoms including depression, anxiety, and seizures, cognitive symptoms, and history of stroke, were positively associated with dementia. Cardiovascular risk factors such as hypertension, heart disease, dyslipidaemia and diabetes were positively associated with VaD and negatively with AD. Sensitivity analyses showed similar results. Conclusions These findings are of potential value in guiding feature selection for a risk prediction tool for dementia in primary care. Limitations include findings being UK-focussed. Further predictive entities ascertainable from primary care data, such as changes in consulting patterns, were absent from the literature and should be explored in future studies

Multi-wavelength lens construction of a Planck and Herschel-detected star-bursting galaxy

We present a source-plane reconstruction of a Herschel and Planck-detected gravitationally lensed dusty star-forming galaxy (DSFG) at z = 1.68 using Hubble, Submillimeter Array (SMA), and Keck observations. The background submillimeter galaxy (SMG) is strongly lensed by a foreground galaxy cluster at z = 0.997 and appears as an arc with a length of ∼15″ in the optical images. The continuum dust emission, as seen by SMA, is limited to a single knot within this arc. We present a lens model with source-plane reconstructions at several wavelengths to show the difference in magnification between the stars and dust, and highlight the importance of multi-wavelength lens models for studies involving lensed DSFGs. We estimate the physical properties of the galaxy by fitting the flux densities to model spectral energy distributions leading to a magnification-corrected starformation rate (SFR) of 390 ± 60 M yr−1 and a stellar mass of 1.1 ± 0.4 10 x 11 M. These values are consistent with high-redshift massive galaxies that have formed most of their stars already. The estimated gas-to-baryon fraction, molecular gas surface density, and SFR surface density have values of 0.43 ± 0.13, 350 ± 200 M pc−2, and ~ 12 7 M yr−1 kpc−2, respectively. The ratio of SFR surface density to molecular gas surface density puts this among the most star-forming systems, similar to other measured SMGs and local ULIRGs

Taxonomy based on science is necessary for global conservation

Peer reviewe

Towards Contemporary Papakāinga Inspired Urban State Housing

With Wellington city set to accommodate up to 80,000 new residents by 2050. An increasing need for affordable housing for lower socioeconomic family groups affected by the current housing and living crisis. The current demand for state housing in urban centres is increasingly high, and for the right type of home needed for large families. However, with Aotearoa New Zealand having a history of state housing intended for a Pākehā way of living, it is arguable that new state housing solutions are only just starting to consider achieving equal outcomes for different ways of living. Although state housing inherently has the duty of supporting equality with affordable homes, it should also be suited to address imbalance in quality of life and allow freedom for different family groups to live how they choose.This thesis’ central concern is to explore design ideas for a social housing and community development that help create adequate homes and improve equitable outcomes, in Aotearoa New Zealand’s cities. At first the research will examine the architectural design of a Papakāinga by following current Māori housing solutions – as Māori disproportionately account for half of the state housing register. After a personal realisation that the research should be within what I know as a Pākehā, the thesis shifts to examine the architectural design of a flexible large family home, urban community, and serving the needs of the families with of varying circumstance, way of life, or composition, including urban Māori.The thesis will achieve this through two design research investigations that explore a new typology for social housing in Aotearoa New Zealand’s cities. The first design research phase examines the design of an urban Papakāinga and the second looks at the large family state home and accompanying community spaces. The purpose of the studies is to address problems in existing state home design that should allow for greater equity and new ways of thinking must solve and illustrated through iterative design ideas. A design brief and criteria were used to evaluate the design research, and was established from literature study, existing housing development typologies, and housing precedents.It concludes with a design that integrates key learnings of the research and recommendations for future social home design and adjoining communities by suggesting it were a method for creating equitable social housing outcomes specific yet flexible to the families and communities who need them, whilst celebrating them as an integral part of the urban environment.</p

Change to costs and lengths of stay in the emergency department and the Brisbane protocol: an observational study

- Objective To compare health service cost and length of stay between a traditional and an accelerated diagnostic approach to assess acute coronary syndromes (ACS) among patients who presented to the emergency department (ED) of a large tertiary hospital in Australia. - Design, setting and participants This historically controlled study analysed data collected from two independent patient cohorts presenting to the ED with potential ACS. The first cohort of 938 patients was recruited in 2008–2010, and these patients were assessed using the traditional diagnostic approach detailed in the national guideline. The second cohort of 921 patients was recruited in 2011–2013 and was assessed with the accelerated diagnostic approach named the Brisbane protocol. The Brisbane protocol applied early serial troponin testing for patients at 0 and 2 h after presentation to ED, in comparison with 0 and 6 h testing in traditional assessment process. The Brisbane protocol also defined a low-risk group of patients in whom no objective testing was performed. A decision tree model was used to compare the expected cost and length of stay in hospital between two approaches. Probabilistic sensitivity analysis was used to account for model uncertainty. - Results Compared with the traditional diagnostic approach, the Brisbane protocol was associated with reduced expected cost of $1229 (95$1266 to $5122) and reduced expected length of stay of 26 h (95% CI −14 to 136 h). The Brisbane protocol allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from ED within 4 h (72% vs 51%). Results from sensitivity analysis suggested the Brisbane protocol had a high chance of being cost-saving and time-saving. - Conclusions This study provides some evidence of cost savings from a decision to adopt the Brisbane protocol. Benefits would arise for the hospital and for patients and their families