Methodological challenges when carrying out research on CKD and AKI using routine electronic health records.

Research regarding chronic kidney disease (CKD) and acute kidney injury (AKI) using routinely collected data presents particular challenges. The availability, consistency, and quality of renal data in electronic health records has changed over time with developments in policy, practice incentives, clinical knowledge, and associated guideline changes. Epidemiologic research may be affected by patchy data resulting in an unrepresentative sample, selection bias, misclassification, and confounding by factors associated with testing for and recognition of reduced kidney function. We systematically explore the issues that may arise in study design and interpretation when using routine data sources for CKD and AKI research. First, we discuss how access to health care and management of patients with CKD may have an impact on defining the target population for epidemiologic study. We then consider how testing and recognition of CKD and AKI may lead to biases and how to potentially mitigate against these. Illustrative examples from our own research within the UK are used to clarify key points. Any research using routine renal data has to consider the local clinical context to achieve meaningful interpretation of the study findings

Draft Genome Sequence of Robinsoniella peoriensis 6600698, a Confounder of Clostridium difficile Diagnosis.

Robinsoniella peoriensis is a Gram-positive, strictly anaerobic, spore-forming, rod-shaped organism. Here, we report the draft genome of R. peoriensis 6600698, initially classified as Clostridium difficile due to growth on selective agar, a fecal gdh PCR-positive result, and clinical symptoms. R. peoriensis is a potential confounder of C. difficile diagnosis

A palaeoecological investigation of long-term stand-scale ecological dynamics in semi-open native pine woods : contributing to conservation management in east Glen Affric

This thesis investigates past structure and dynamics of native Caledonian pine woodland, representing part of the western fringes of the northern European boreal woodlands. The biogeographical extent and Holocene history of the Scottish pine woods are well studied, yet questions remain at finer scales. This thesis is concerned with two factors over the recent Holocene oceanic period; (i) the long-term ecology within the woods; the spatio-temporal dynamics, the canopy structure, and community composition and continuity; and (ii) the former extent of the woods, especially the temporal pattern of the inferred easterly contraction in woodland over recent history. The importance of these factors - to ecologists, challenged with understanding the theories of equilibrium and non-equilibrium processes in long-lived woodland communities - and to conservation managers - challenged, by policy directives, with implementing the restoration and expansion of native woodlands - is discussed. Equally the identification and quantification of ecological detail over ecologically relevant temporal and spatial scales is an important challenge for palaeoecology. The thesis therefore applies fine spatial resolution pollen analyses over a network of sites, within, and at the western edge of, the extant woodland zone in east Glen Affric. Correlation between these individual site histories develops a detailed view of the grain and extent of woodland within the landscape, previously missing from western pine woods. Careful attention is paid to the interpretive potential and limitations of fine resolution palaeoecology; especially with regard (i) to techniques that can identify and spatially quantify stand-scale structure and community composition via reference to modern analogues; and (ii) to defining chronologies and elucidating rates and patterns of temporal change. The opportunities and limitations of the technique are explored and discussed, to ensure an understanding of the rigour and potential of the palaeoecological contribution to ecological research and to provide an evidence base for conservation. The application of 210Pb dating using the CRS and CIC models is explored. The CRS model is confirmed as suitable for peat deposits, but its use may mask fluctuations in peat sedimentation rate, which may be illustrated by the CIC model. The value of multiple 14C assays for each core and a need for a new approach to chronologies for application to fine-scale palaeecological studies is discussed. The relevant source area around the small basins in this semi-open pinewood is tentatively confirmed at 20 m from the pollen source. Tentative pollen productivity estimates for five key taxa in this ecosystem are presented. The temporal stability of native woodland in Glen Affric is confirmed to the eastern part of the extant woodland zone; but challenged to the west, where the open and semi-open landscape has a long history. Woodland diversity decreased over the last c. 200 years, and past woodland also shows a greater ground flora diversity. The western extent of the Caledonian woodland in this landscape may have changed little in the last c. 4000 years. Fluctuations, some clearly cyclical, in heath, and in woodland, communities are identified in the pollen record. The former may be aligned to changes in grazing regime or climatic shifts; and the latter to autochthonous shifts important in the maintenance of suitable edaphic conditions for the continuity of woodland. Former woodland is confirmed as likely to have been open in structure and mixed in tree species composition. The results presented here suggest that some caution should be applied to use of the term Caledonian, or native ‘pine’ forest: ‘Caledonian forest’ may better reflect the heterogeneity of past forests, particularly the importance, and persistence, of birch. The implications for conservation management and restoration are discussed. It may be difficult to establish a sustainable woodland to the west of the extant stands, and any pine woodland here may need to be mixed with stands of broadleaved trees to maintain or restore soil structure and ecological function. The landscape to the west may have been open for several thousands of years, and consideration of this is required when managing for the future to prevent loss of biodiversity.EThOS - Electronic Theses Online ServiceUniversity of Stirling : Forest ResearchGBUnited Kingdo

“We can all just get on a bus and go” : Rethinking independent mobility in the context of the universal provision of free bus travel to young Londoners

This paper uses qualitative data from interviews with 118 young Londoners (age 12-18) to examine how the universal provision of free bus travel has affected young people’s independent mobility. Drawing on Sen’s ‘capabilities approach’, we argue that free bus travel enhanced young Londoners’ capability to shape their daily mobility, both directly by increasing financial access and indirectly by facilitating the acquisition of the necessary skills, travelling companions and confidence. These capabilities in turn extended both opportunity freedoms (e.g. facilitating non-“necessary” recreational and social trips) and process freedoms (e.g. feeling more independent by decreasing reliance on parents). Moreover, the universal nature of the entitlement rendered buses a socially inclusive way for groups to travel and spend time together, thereby enhancing group-level capabilities. We believe this attention to individual and group capabilities for self-determination provides the basis for a broader and more child-centred view of ‘independent mobility’ than the typical research focus upon ‘travelling without an adult’ and acquiring parental permissions.Peer reviewe

How parents and children evaluate emollients for childhood eczema: a qualitative study

BACKGROUND: Eczema affects one in five children in the UK. Regular application of emollients is routinely recommended for children with eczema. There are four main emollient types, but no clear evidence of which is best. The current ‘trial and error’ approach to find suitable emollients can be frustrating for parents, children, and clinicians. AIM: To identify how parents and children experience and evaluate emollients. DESIGN AND SETTING: Qualitative interview study, nested within a primary care trial of emollients (Best Emollients for Eczema [BEE] trial). METHOD: Semi-structured interviews with children with eczema and their parents were conducted. Participants were purposively sampled on emollient type (lotion, cream, gel, or ointment), age, and eczema severity. RESULTS: Forty-four parents were interviewed, with children participating in 24 of those interviews. There was no clear preference for any one emollient type. The strongest theme was the variation of experience in each of the four types. Participants focused on thickness and absorbency, both positively and negatively, to frame their evaluations. Effectiveness and acceptability were both considered when evaluating an emollient but effectiveness was the primary driver for continued use. For some, participating in the trial had changed their knowledge and behaviour of emollients, resulting in use that was more regular and for a longer duration. CONCLUSION: There is no one emollient that is suitable for everyone, and parents/children prioritise different aspects of emollients. Future research could evaluate decision aids and/or tester pots of different types, which could enable clinicians and parents/children to work collaboratively to identify the best emollient for them

Patient preferences in tinnitus outcomes and treatments:a qualitative study

In order to identify patient preferences in care for tinnitus an in depth grounded theory study was conducted. This consisted of interviews with 41 patients who had sought help for tinnitus across a range of locations and tinnitus services in England. Preferences for outcomes were for both the removal of the tinnitus and for improved coping and management of the tinnitus. Preferences for treatment were for individualized care, tailored information and for treatment to assist with psychological adjustment and auditory distraction. Adoption of treatments to manage tinnitus were based on a trial and error approach. Patients? preferences for individual treatments varied but were informed by the information they received. Information plays an important role in care for people with tinnitus. Patients hold individual preferences and require engagement in shared decision making

The development of a decision aid for tinnitus

OBJECTIVE: To develop a decision aid for tinnitus care that would meet international consensus for decision aid quality. DESIGN: A mixed methods design that included qualitative in-depth interviews, literature review, focus groups, user testing and readability checking. STUDY SAMPLE: Patients and clinicians who have clinical experience of tinnitus. RESULTS: A decision aid for tinnitus care was developed. This incorporates key evidence of efficacy for the most frequently used tinnitus care options, together with information derived from patient priorities when deciding which choice to make. CONCLUSION: The decision aid has potential to enable shared decision making between clinicians and patients in audiology. The decision aid meets consensus standards

Ethnic differences in Glycaemic control in people with type 2 diabetes mellitus living in Scotland

Background and Aims: Previous studies have investigated the association between ethnicity and processes of care and intermediate outcomes of diabetes, but there are limited population-based studies available. The aim of this study was to use population-based data to investigate the relationships between ethnicity and glycaemic control in men and women with diabetes mellitus living in Scotland.<p></p> Methods: We used a 2008 extract from the population-based national electronic diabetes database of Scotland. The association between ethnicity with mean glycaemic control in type 2 diabetes mellitus was examined in a retrospective cohort study, including adjustment for a number of variables including age, sex, socioeconomic status, body mass index (BMI), prescribed treatment and duration of diabetes.<p></p> Results: Complete data for analyses were available for 56,333 White Scottish adults, 2,535 Pakistanis, 857 Indians, 427 Chinese and 223 African-Caribbeans. All other ethnic groups had significantly (p<0.05) greater proportions of people with suboptimal glycaemic control (HbA1c >58 mmol/mol, 7.5%) compared to the White Scottish group, despite generally younger mean age and lower BMI. Fully adjusted odds ratios for suboptimal glycaemic control were significantly higher among Pakistanis and Indians (1.85, 95% CI: 1.68–2.04, and 1.62,95% CI: 1.38–1.89) respectively.<p></p> Conclusions: Pakistanis and Indians with type 2 diabetes mellitus were more likely to have suboptimal glycaemic control than the white Scottish population. Further research on health services and self-management are needed to understand the association between ethnicity and glycaemic control to address ethnic disparities in glycaemic control.<p></p&gt

Children With Cystic Fibrosis Are Infected With Multiple Subpopulations of Mycobacterium abscessus With Different Antimicrobial Resistance Profiles.

BACKGROUND: Children with cystic fibrosis (CF) can develop life-threatening infections of Mycobacterium abscessus. These present a significant clinical challenge, particularly when the strains involved are resistant to antibiotics. Recent evidence of within-patient subclones of M. abscessus in adults with CF suggests the possibility that within-patient diversity may be relevant for the treatment of pediatric CF patients. METHODS: We performed whole-genome sequencing (WGS) on 32 isolates of M. abscessus that were taken from multiple body sites of 2 patients with CF who were undergoing treatment at Great Ormond Street Hospital, United Kingdom, in 2015. RESULTS: We found evidence of extensive diversity within patients over time. A clustering analysis of single nucleotide variants revealed that each patient harbored multiple subpopulations, which were differentially abundant between sputum, lung samples, chest wounds, and pleural fluid. The sputum isolates did not reflect the overall within-patient diversity and did not allow for the detection of subclones with mutations previously associated with macrolide resistance (rrl 2058/2059). Some variants were present at intermediate frequencies before the lung transplants. The time of the transplants coincided with extensive variation, suggesting that this event is particularly disruptive for the microbial community, but the transplants did not clear the M. abscessus infections and both patients died as a result of these infections. CONCLUSIONS: Isolates of M. abscessus from sputum do not always reflect the entire diversity present within the patient, which can include subclones with differing antimicrobial resistance profiles. An awareness of this phenotypic variability, with the sampling of multiple body sites in conjunction with WGS, may be necessary to ensure the best treatment for this vulnerable patient group