Expanding Disease Definitions in Guidelines and Expert Panel Ties to Industry:A Cross-sectional Study of Common Conditions in the United States

BACKGROUND: Financial ties between health professionals and industry may unduly influence professional judgments and some researchers have suggested that widening disease definitions may be one driver of over-diagnosis, bringing potentially unnecessary labeling and harm. We aimed to identify guidelines in which disease definitions were changed, to assess whether any proposed changes would increase the numbers of individuals considered to have the disease, whether potential harms of expanding disease definitions were investigated, and the extent of members' industry ties. METHODS AND FINDINGS: We undertook a cross-sectional study of the most recent publication between 2000 and 2013 from national and international guideline panels making decisions about definitions or diagnostic criteria for common conditions in the United States. We assessed whether proposed changes widened or narrowed disease definitions, rationales offered, mention of potential harms of those changes, and the nature and extent of disclosed ties between members and pharmaceutical or device companies. Of 16 publications on 14 common conditions, ten proposed changes widening and one narrowing definitions. For five, impact was unclear. Widening fell into three categories: creating “pre-disease”; lowering diagnostic thresholds; and proposing earlier or different diagnostic methods. Rationales included standardising diagnostic criteria and new evidence about risks for people previously considered to not have the disease. No publication included rigorous assessment of potential harms of proposed changes. Among 14 panels with disclosures, the average proportion of members with industry ties was 75%. Twelve were chaired by people with ties. For members with ties, the median number of companies to which they had ties was seven. Companies with ties to the highest proportions of members were active in the relevant therapeutic area. Limitations arise from reliance on only disclosed ties, and exclusion of conditions too broad to enable analysis of single panel publications. CONCLUSIONS: For the common conditions studied, a majority of panels proposed changes to disease definitions that increased the number of individuals considered to have the disease, none reported rigorous assessment of potential harms of that widening, and most had a majority of members disclosing financial ties to pharmaceutical companies. Please see later in the article for the Editors' Summar

Slow gait speed and cardiac rehabilitation participation in older adults after acute myocardial infarction

Background Lack of participation in cardiac rehabilitation ( CR ) and slow gait speed have both been associated with poor long‐term outcomes in older adults after acute myocardial infarction ( AMI ). Whether the effect of CR participation on outcomes after AMI differs by gait speed is unknown. Methods and Results We examined the association between gait speed and CR participation at 1 month after discharge after AMI , and death and disability at 1 year, in 329 patients aged ≥65 years enrolled in the TRIUMPH (Translational Research Investigating Underlying Disparities in Recovery From Acute Myocardial Infarction: Patients' Health Status) registry. Among these patients, 177 (53.7%) had slow gait speed (&lt;0.8 m/s) and 109 (33.1%) participated in CR . Patients with slow gait speed were less likely to participate in CR compared with patients with normal gait speed (27.1% versus 40.1%; P =0.012). In unadjusted analysis, CR participants with normal gait speed had the lowest rate of death or disability at 1 year (9.3%), compared with those with slow gait speed and no CR participation (43.2%). After adjustment for cardiovascular risk factors and cognitive impairment, both slow gait speed (odds ratio, 2.30; 95% confidence interval, 1.30–4.06) and non‐ CR participation (odds ratio, 2.34; 95 confidence interval, 1.22–4.48) were independently associated with death or disability at 1 year. The effect of CR on the primary outcome did not differ by gait speed ( P =0.70). Conclusions CR participation is associated with reduced risk for death or disability after AMI . The beneficial effect of CR participation does not differ by gait speed, suggesting that slow gait speed alone should not preclude referral to CR for older adults after AMI . </jats:sec

Growing Pains or Opportunities? A Customer Survey of Three Farmers\u27 Markets in One Rural Community

The continued growth of farmers\u27 markets is presenting new challenges to Extension. As the number of markets expands, how can Extension help those in the same community work together for mutual benefit? The study reported here examined similarities and differences among customers attending three different farmers\u27 markets within a single locality in Gettysburg, Pennsylvania. Based on 370 customer surveys, study results underscore the diversity of markets operating within the same community and provide insights into ways Extension might assist markets to work together to expand their shared customer base, increase revenues, and better serve local residents

BOSS Ultracool Dwarfs I: Colors and Magnetic Activity of M and L dwarfs

We present the colors and activity of ultracool (M7-L8) dwarfs from the Tenth Data Release of the Sloan Digital Sky Survey (SDSS). We combine previous samples of SDSS M and L dwarfs with new data obtained from the Baryon Oscillation Sky Survey (BOSS) to produce the BOSS Ultracool Dwarf (BUD) sample of 11820 M7-L8 dwarfs. By combining SDSS data with photometry from the Two Micron All Sky Survey and the Wide-Field Infrared Sky Explorer mission, we present ultracool dwarf colors from $i-z$ to $W2-W3$ as a function of spectral type, and extend the SDSS-2MASS-WISE color locus to include ultracool dwarfs. The $i-z$, $i-J$, and $z-J$ colors provide the best indication of spectral type for M7-L3 dwarfs. We also examine ultracool dwarf chromospheric activity through the presence and strength of H$\alpha$ emission. The fraction of active dwarfs rises through the M spectral sequence until it reaches $\sim$90% at spectral type L0. The fraction of active dwarfs then declines to 50% at spectral type L5; no H$\alpha$ emission is observed in the late-L dwarfs in the BUD sample. The fraction of active L0-L5 dwarfs is much higher than previously observed. The strength of activity declines with spectral type from M7 through L3, after which the data do not show a clear trend. Using one-dimensional chromosphere models, we explore the range of filling factors and chromospheric temperature structures that are consistent with H$\alpha$ observations of M0-L7 dwarfs. M dwarf chromospheres have a similar, smoothly varying range of temperature and surface coverage while L dwarf chromospheres are cooler and have smaller filling factors.Comment: 24 pages and 13 figures, submitted to AJ. A short video describing these results can be found at https://www.youtube.com/watch?v=wwX5WkuJCU

International chicken trade and increased risk for introducing or reintroducing highly pathogenic avian influenza A (H5N1) to uninfected countries.

Every year billions of chickens are shipped thousands of miles around the globe in order to meet the ever increasing demands for this cheap and nutritious protein source. Unfortunately, transporting chickens internationally can also increase the chance for introducing zoonotic viruses, such as highly pathogenic avian influenza A (H5N1) to new countries. Our study used a retrospective analysis of poultry trading data from 2003 through 2011 to assess the risk of H5N1 poultry infection in an importing country. We found that the risk of infection in an importing country increased by a factor of 1.3 (95% CI: 1.1-1.5) for every 10-fold increase in live chickens imported from countries experiencing at least one H5N1 poultry case during that year. These results suggest that the risk in a particular country can be significantly reduced if imports from countries experiencing an outbreak are decreased during the year of infection or if biosecurity measures such as screening, vaccination, and infection control practices are increased. These findings show that limiting trade of live chickens or increasing infection control practices during contagious periods may be an important step in reducing the spread of H5N1 and other emerging avian influenza viruses

Modelling solar-like variability for the detection of Earth-like planetary transits. II. Performance of the three-spot modelling, harmonic function fitting, iterative nonlinear filtering, and sliding boxcar filtering

Copyright © The European Southern Observatory (ESO)Aims. As an extension of a previous work, we present a comparison of four methods of filtering solar-like variability to increase the efficiency of detection of Earth-like planetary transits by means of box-shaped transit finder algorithms. Two of these filtering methods are the harmonic fitting method and the iterative nonlinear filter that, coupled respectively with the box least-square (BLS) and box maximum likelihood algorithms, demonstrated the best performance during the first detection blind test organised inside the CoRoT consortium. The third method, the 3-spot model, is a simplified physical model of Sun-like variability and the fourth is a simple sliding boxcar filter. Methods. We apply a Monte Carlo approach by simulating a large number of 150-day light curves (as for CoRoT long runs) for different planetary radii, orbital periods, epochs of the first transit, and standard deviations of the photon shot noise. Stellar variability is given by the total solar irradiance variations as observed close to the maximum of solar cycle 23. After filtering solar variability, transits are searched for by means of the BLS algorithm. Results. We find that the iterative nonlinear filter is the best method for filtering light curves of solar-like stars when a suitable window can be chosen. As the performance of this filter depends critically on the length of its window, we point out that the window must be as long as possible, according to the magnetic activity level of the star. We show an automatic method to choose the extension of the filter window from the power spectrum of the light curves. Conclusions. The iterative nonlinear filter, when used with a suitable choice of its window, has a better performance than more complicated and computationally intensive methods of fitting solar-like variability, like the 200-harmonic fitting or the 3-spot model

Predictors and outcomes of sustained, intermittent or never achieving remission in patients with recent onset inflammatory polyarthritis:Results from the Norfolk Arthritis Register

Objectives: Early remission is the current treatment strategy for patients with inflammatory polyarthritis (IP) and RA. Our objective was to identify baseline factors associated with achieving remission: sustained (SR), intermittent (IR) or never (NR) over a 5-year period in patients with early IP.  Methods: Clinical and demographic data of patients with IP recruited to the Norfolk Arthritis Register (NOAR) were obtained at baseline and years 1, 2, 3 and 5. Remission was defined as no tender or swollen joints (out of 51). Patients were classified as NR or PR, respectively, if they were in remission at: no assessment or ⩾3 consecutive assessments after baseline, and IR otherwise. Ordinal regression and a random effects model, respectively, were used to examine the association between baseline factors, remission group and HAQ scores over time.  Results: A total of 868 patients (66% female) were included. Of these, 54%, 34% and 12% achieved NR, IR and SR, respectively. In multivariate analysis, female sex (odds ratio, OR 0.47, 95% CI: 0.35, 0.63), higher tender joint count (OR = 0.94, 95% CI: 0.93, 0.96), higher HAQ (OR = 0.59, 95% CI: 0.48, 0.74), being obese (OR = 0.70, 95% CI: 0.50, 0.99), hypertensive (OR = 0.67, 95% CI: 0.50, 0.90) or depressed (OR = 0.74, 95% CI: 0.55, 1.00) at baseline were independent predictors of being in a lower remission group. IR and SR were associated with lower HAQ scores over time and lower DAS28 at year 5.  Conclusion: Women with higher tender joint count and disability at baseline, depression, obesity and hypertension were less likely to achieve remission. This information could help when stratifying patients for more aggressive therapy

Defining Remoteness from Health Care: Integrated Research on Accessing Emergency Maternal Care in Indonesia<br />

The causes of maternal death are well known, and are largely preventable if skilled health care is received promptly. Complex interactions between geographic and socio-cultural factors affect access to, and remoteness from, health care but research on this topic rarely integrates spatial and social sciences. In this study, modeling of travel time was integrated with social science research to refine our understanding of remoteness from health care. Travel time to health facilities offering emergency obstetric care (EmOC) and population distribution were modelled for a district in eastern Indonesia. As an index of remoteness, the proportion of the population more than two hours estimated travel time from EmOC was calculated. For the best case scenario (transport by ambulance in the dry season), modelling estimated more than 10,000 fertile aged women were more than two hours from EmOC. Maternal mortality ratios were positively correlated with the remoteness index, however there was considerable variation around this relationship. In a companion study, ethnographic research in a subdistrict with relatively good access to health care and high maternal mortality identified factors influencing access to EmOC, including some that had not been incorporated into the travel time model. Ethnographic research provided information about actual travel involved in requesting and reaching EmOC. Modeled travel time could be improved by incorporating time to deliver request for care. Further integration of social and spatial methods and the development of more dynamic travel time models are needed to develop programs and policies to address these multiple factors to improve maternal health outcomes